Veliparib With or Without Radiation Therapy, Carboplatin, and Paclitaxel in Patients With Stage III Non-small Cell Lung Cancer That Cannot Be Removed by Surgery
Phase 1/2 – combined early trial
Conditions:
Lung Adenocarcinoma
Lung Adenocarcinoma, Mixed Subtype
Lung Large Cell Carcinoma
Lung Squamous Cell Carcinoma
Minimally Invasive Lung Adenocarcinoma
Stage III Lung Non-Small Cell Cancer AJCC v7
Stage IIIA Lung Non-Small Cell Cancer AJCC v7
Stage IIIB Lung Non-Small Cell Cancer AJCC v7
Sponsor: National Cancer Institute (NCI)
trial.available_in:
БГ
Overview
This phase I/II partially randomized trial studies the side effects and best dose of veliparib when given together with radiation therapy, carboplatin, and paclitaxel and to see how well it works in treating patients with stage III non-small cell lung cancer that cannot be removed by surgery. Veliparib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Radiation therapy uses high energy x-rays to kill tumor cells and shrink tumors. Drugs used in chemotherapy, such as carboplatin and paclitaxel, work in different ways to stop the growth of tumor cells either by killing the cells, by stopping them from dividing, or by stopping them from spreading. It is not yet known whether radiation therapy, carboplatin, and paclitaxel are more effective with or without veliparib in treating non-small cell lung cancer.
Description
PRIMARY OBJECTIVES:
I. To establish the maximum tolerated dose (MTD) and the recommended phase II dose of ABT-888 (veliparib) when given concurrently with standard carboplatin/paclitaxel and radiotherapy in patients with unresectable stage III non-small cell lung cancer (NSCLC). (Phase I) II. To assess whether carboplatin/paclitaxel plus ABT-888 compared with carboplatin/paclitaxel plus placebo improves progression-free survival (PFS) in patients with unresectable stage III NSCLC. (Phase II) III. To compare overall survival (OS) in patients treated with carboplatin/paclitaxel and radiotherapy plus ABT-888 to those treated with carboplatin, paclitaxel and radiotherapy plus placebo. (Phase II) IV. To assess the response rate (confirmed and unconfirmed, complete and partial responses) and disease control rate in the subset of patients with measurable disease by Response Evaluation Criteria in Solid Tumors (RECIST) criteria. (Phase II) V. To assess the safety and toxicity profile of the regimen. (Phase II)
SECONDARY OBJECTIVES:
I. To collect tumor tissue from pretreatment biopsies (archival samples) for biomarker studies, including poly (ADP-ribose) polymerase 1 (PARP) activity by measuring the levels of poly-ADP-ribose, gamma-H2A histone family, member X (gamma-H2AX), and messenger ribonucleic acid (mRNA) expression levels of deoxyribonucleic acid (DNA) repair enzymes such as excision repair cross-complementing rodent repair deficiency, complementation group 1 (ERCC1)/x-ray repair complementing defective repair in Chinese hamster cells 1 (XRCC1).
II. To collect blood samples for evaluation of gamma-H2AX (circulating tumor cells) and other relevant future studies.
OUTLINE: This is a phase I, dose-escalation study of veliparib followed by a randomized phase II study.
PHASE I:
INDUCTION THERAPY: Patients undergo 3-dimensional conformal radiation therapy (3D-CRT) once daily (QD), 5 days a week, for 6 weeks. Patients also receive veliparib orally (PO) twice daily (BID) on days 1-43 and carboplatin intravenously (IV) over 30 minutes and paclitaxel IV over 1 hour on days 1, 8, 15, 22, 36, and 43 in the absence of disease progression or unacceptable toxicity. Patients without disease progression after completion of chemoradiotherapy undergo consolidation therapy.
CONSOLIDATION THERAPY: Beginning within 4-6 weeks of chemotherapy and radiation therapy, patients receive veliparib PO BID on days 1-7 (course 1) and 22-28 (course 2) and carboplatin IV over 30 minutes and paclitaxel IV over 3 hours on day 1 and on day 22 of course 2. Treatment repeats every 21 days for 2 courses in the absence of disease progression or unacceptable toxicity.
PHASE II: Patients are randomized to 1 of 2 treatment arms.
ARM I: Patients undergo 3D-CRT and receive veliparib, carboplatin, and paclitaxel as in Phase I induction and consolidation therapy.
ARM II: Patients undergo 3D-CRT as in arm I. Patients also receive placebo PO BID on days 1-43 and carboplatin and paclitaxe
Who can participate
Inclusion Criteria:
* Patients must have histologically or cytologically-proven new diagnosis of unresectable stage IIIA/IIIB\*, non-small cell lung cancer (adenocarcinoma, bronchioloalveolar cell carcinoma, large cell carcinoma, squamous cell carcinoma, or mixed)
* Per the American Joint Committee on Cancer (AJCC) 7th edition, pleural and pericardial are now considered stage M1a disease; when pleural fluid is visible on the computed tomography (CT) scan or on a chest x-ray, a thoracentesis is required to confirm that the pleural fluid is cytologically negative; patients with exudative pleural effusions are excluded, regardless of cytology; patients with effusions that are minimal (i.e. not visible on chest x-ray) that are too small to safely tap are eligible; a small effusion that has positive fludeoxyglucose F 18 (FDG) uptake on positron emission tomography (PET) has to be proven to be malignant per standard of care diagnostic procedures for the patient to be excluded
* Patients must have measurable or non-measurable disease documented by CT, magnetic resonance imaging (MRI) or PET/CT; the CT from a combined PET/CT may be used to document only non-measurable disease unless the scan is of diagnostic quality; measurable disease must be assessed by CT within 28 days prior to registration; pleural effusions, ascites and laboratory parameters are not acceptable as the only evidence of disease; non-measurable disease must be assessed within 42 days prior to registration; all disease must be assessed and documented on the Baseline Tumor Assessment Form
* Patients with brain metastases are ineligible; all patients must have a pretreatment CT or MRI scan of the brain to evaluate for central nervous system (CNS) disease within 42 days prior to registration
* Patients must not have received any prior systemic therapy (chemotherapy or other biologic therapy) for lung cancer
* Patients must not have received prior chest radiation therapy for NSCLC
* Patients must not have had a previous surgical resection; however, patients may have undergone exploratory thoracotomy, mediastinoscopy, excisional biopsy or similar surgery for the purpose of determining the diagnosis, stage or potential resectability of newly diagnosed lung tumor; at least 28 days must have elapsed since thoracic surgery (excluding mediastinoscopy or other minor surgeries) and patients should have recovered from all associated toxicities at the time of registration; patients must not be planning to undergo a minor surgical procedure while on this study
* Patients must have Zubrod performance status 0-1
* Patients must have tumor tissue available for submission to assess gene expression of ERCC1 and XRCC1; patients must also be offered participation in banking for future use of specimens
* Absolute neutrophil count \>= 1,500/mcl
* Platelets \>= 100,000/mcl
* Hemoglobin \>= 9.0 g/dl
* Total bilirubin within institutional upper limit of normal (IULN)
* Serum glutamic oxaloacetic transaminase (SGOT) (aspartate aminotransferase \[AST\]) or serum glutamate pyruvate transaminase (SGPT) (alanine aminotransferase \[ALT\]) =\< 2.5 x IULN
* Patients must not be pregnant or nursing; women/men of reproductive potential must have agreed to use an effective contraceptive method; a woman is considered to be of "reproductive potential" if she has had menses at any time in the preceding 12 consecutive months; in addition to routine contraceptive methods, "effective contraception" also includes heterosexual celibacy and surgery intended to prevent pregnancy (or with a side-effect of pregnancy prevention) defined as a hysterectomy, bilateral oophorectomy or bilateral tubal ligation; however, if at any point a previously celibate patient chooses to become heterosexually active during the time period for use of contraceptive measures outlined in the protocol, he/she is responsible for beginning contraceptive measures
* Patients must have a serum creatinine =\< the IULN AND measured or calculated creatinine clearance \>= 60 cc/min using the Cockroft-Gault formula
* Patients must have pulmonary function tests (PFTs) including forced expiratory volume in 1 second (FEV1) within 84 days prior to registration; for FEV1, the best value obtained pre- or post-bronchodilator must be \>= 1.2 liters/second and/or \>= 50% predicted
* Patients may not be planning to receive any other investigational agents
* Patients must not have more than 10% weight loss in the past 6 months
* Patients must not have a history of allergic reactions attributed to compounds of similar chemical or biologic composition to ABT-888, carboplatin, paclitaxel or other agents used in study
* No other prior malignancy is allowed except for the following: adequately treated basal cell or squamous cell skin cancer, in situ cervical cancer, adequately treated stage I or II cancer from which the patient is currently in complete remission, or any other cancer from which the patient has been disease free for five years
* Patient must not have any uncontrolled intercurrent illness including, but not limited to ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements
* Patients must not currently have a \> grade 1 symptomatic neuropathy-sensory (National Cancer Institute \[NCI\] Common Terminology Criteria for Adverse Events \[CTCAE\] version 4.0)
* Patients must not have a history of seizures
* Patients must not have any known immune deficiencies; patients with immune deficiency are at increased risk of lethal infections when treated with marrow-suppressive therapy; therefore, known human immunodeficiency virus (HIV) positive patients receiving combination anti-retroviral therapy are excluded from the study
* Patients must be able to swallow whole capsules
* Prestudy history and physical must be obtained within 28 days prior to registration
* All patients must be informed of the investigational nature of this study and must sign and give written informed consent in accordance with institutional and federal guidelines
* As a part of the Oncology Patient Enrollment Network (OPEN) registration process the treating institution's identity is provided in order to ensure that the current (within 365 days) date of institutional review board approval for this study has been entered in the system
* REGISTRATION #2 - PRIOR TO CONSOLIDATION CHEMOTHERAPY:
* REGISTRATION #2 - PRIOR TO CONSOLIDATION CHEMOTHERAPY: Patients must have completed chemoradiotherapy per protocol and at least four weeks but no more than six weeks must have elapsed from the last day of induction therapy (the last day of radiation)
* REGISTRATION #2 - PRIOR TO CONSOLIDATION CHEMOTHERAPY: Patients must have undergone restaging tests according to the study calendar and determined to have no evidence of disease progression
* REGISTRATION #2 - PRIOR TO CONSOLIDATION CHEMOTHERAPY: Patients must have a serum creatinine =\< (IULN) AND measured of calculated creatinine clearance \>= 60 cc/min using the Cockroft-Gault formula
* REGISTRATION #2 - PRIOR TO CONSOLIDATION CHEMOTHERAPY: Absolute neutrophil count \>= 1,500 mcl
* REGISTRATION #2 - PRIOR TO CONSOLIDATION CHEMOTHERAPY: Platelets \>= 100,000/mcl
* REGISTRATION #2 - PRIOR TO CONSOLIDATION CHEMOTHERAPY: Hemoglobin \>= 9.0 g/dl
* REGISTRATION #2 - PRIOR TO CONSOLIDATION CHEMOTHERAPY: Total bilirubin =\< IULN
* REGISTRATION #2 - PRIOR TO CONSOLIDATION CHEMOTHERAPY: SGOT (AST) or SGPT (ALT) =\< 2.5 x IULN
* REGISTRATION #2 - PRIOR TO CONSOLIDATION CHEMOTHERAPY: Patients must have Zubrod performance status 0-1
Interventions
3-Dimensional Conformal Radiation Therapy
RADIATION
Carboplatin
DRUG
Laboratory Biomarker Analysis
OTHER
Paclitaxel
DRUG
Placebo Administration
OTHER
Veliparib
DRUG
Locations
234
United States (234)
Pali Momi Medical Center
‘Aiea , Hawaii
Queen's Cancer Center - Pearlridge
‘Aiea , Hawaii
The Cancer Center of Hawaii-Pali Momi
‘Aiea , Hawaii
Providence Regional Cancer System-Aberdeen
Aberdeen , Washington
McFarland Clinic - Ames
Ames , Iowa
Community Hospital of Anaconda
Anaconda , Montana
Anchorage Associates in Radiation Medicine
Anchorage , Alaska
Alaska Breast Care and Surgery LLC
Anchorage , Alaska
Alaska Oncology and Hematology LLC
Anchorage , Alaska
Alaska Women's Cancer Care
Anchorage , Alaska
Anchorage Oncology Centre
Anchorage , Alaska
Katmai Oncology Group
Anchorage , Alaska
Providence Alaska Medical Center
Anchorage , Alaska
UCHealth University of Colorado Hospital
Aurora , Colorado
Rush-Copley Medical Center
Aurora , Illinois
Mercy Oncology and Hematology - Clayton-Clarkson
Ballwin , Missouri
Bronson Battle Creek
Battle Creek , Michigan
PeaceHealth Saint Joseph Medical Center
Bellingham , Washington
Sanford Joe Lueken Cancer Center
Bemidji , Minnesota
Saint Charles Health System
Bend , Oregon
Tower Cancer Research Foundation
Beverly Hills , California
Billings Clinic Cancer Center
Billings , Montana
Sanford Bismarck Medical Center
Bismarck , North Dakota
OSF Saint Joseph Medical Center
Bloomington , Illinois
Illinois CancerCare-Bloomington
Bloomington , Illinois
Saint Luke's Cancer Institute - Boise
Boise , Idaho
Parkland Health Center-Bonne Terre
Bonne Terre , Missouri
Bozeman Health Deaconess Hospital
Bozeman , Montana
Providence Saint Joseph Medical Center/Disney Family Cancer Center
Burbank , California
Lahey Hospital and Medical Center
Burlington , Massachusetts
Cleveland Clinic Mercy Hospital
Canton , Ohio
Illinois CancerCare-Canton
Canton , Illinois
Mercy Cancer Center - Cape Girardeau
Cape Girardeau , Missouri
Saint Francis Medical Center
Cape Girardeau , Missouri
Memorial Hospital of Carbondale
Carbondale , Illinois
SIH Cancer Institute
Carterville , Illinois
Illinois CancerCare-Carthage
Carthage , Illinois
Dayton Physicians LLC-Miami Valley South
Centerville , Ohio
Miami Valley Hospital South
Centerville , Ohio
Providence Regional Cancer System-Centralia
Centralia , Washington
Centralia Oncology Clinic
Centralia , Illinois
Cancer Center of Kansas - Chanute
Chanute , Kansas
Northwestern University
Chicago , Illinois
Oncology Hematology Care Inc-Kenwood
Cincinnati , Ohio
Clackamas Radiation Oncology Center
Clackamas , Oregon
Providence Cancer Institute Clackamas Clinic
Clackamas , Oregon
Billings Clinic-Cody
Cody , Wyoming
Kootenai Health - Coeur d'Alene
Coeur d'Alene , Idaho
Baptist Memorial Hospital and Cancer Center-Collierville
Collierville , Tennessee
Bay Area Hospital
Coos Bay , Oregon
City of Hope Corona
Corona , California
Carle at The Riverfront
Danville , Illinois
Good Samaritan Hospital - Dayton
Dayton , Ohio
Miami Valley Hospital
Dayton , Ohio
Dayton Physician LLC - Englewood
Dayton , Ohio
Miami Valley Hospital North
Dayton , Ohio
Cancer Care Specialists of Illinois - Decatur
Decatur , Illinois
Wayne State University/Karmanos Cancer Institute
Detroit , Michigan
Henry Ford Hospital
Detroit , Michigan
Cancer Center of Kansas - Dodge City
Dodge City , Kansas
City of Hope Comprehensive Cancer Center
Duarte , California
Swedish Cancer Institute-Edmonds
Edmonds , Washington
Carle Physician Group-Effingham
Effingham , Illinois
Crossroads Cancer Center
Effingham , Illinois
Cancer Center of Kansas - El Dorado
El Dorado , Kansas
Illinois CancerCare-Eureka
Eureka , Illinois
Providence Regional Cancer Partnership
Everett , Washington
Sanford Broadway Medical Center
Fargo , North Dakota
Sanford Roger Maris Cancer Center
Fargo , North Dakota
Armes Family Cancer Center
Findlay , Ohio
Blanchard Valley Hospital
Findlay , Ohio
Orion Cancer Care
Findlay , Ohio
Cancer Center of Kansas - Fort Scott
Fort Scott , Kansas
Fort Wayne Medical Oncology and Hematology Inc-Parkview
Fort Wayne , Indiana
Atrium Medical Center-Middletown Regional Hospital
Franklin , Ohio
Dayton Physicians LLC-Atrium
Franklin , Ohio
Saint Luke's Cancer Institute - Fruitland
Fruitland , Idaho
Illinois CancerCare-Galesburg
Galesburg , Illinois
Western Illinois Cancer Treatment Center
Galesburg , Illinois
Saint Catherine Hospital
Garden City , Kansas
Corewell Health Grand Rapids Hospitals - Butterworth Hospital
Grand Rapids , Michigan
Trinity Health Grand Rapids Hospital
Grand Rapids , Michigan
Central Care Cancer Center - Great Bend
Great Bend , Kansas
Benefis Sletten Cancer Institute
Great Falls , Montana
Great Falls Clinic
Great Falls , Montana
Dayton Physicians LLC-Wayne
Greenville , Ohio
Wayne Hospital
Greenville , Ohio
HaysMed
Hays , Kansas
Saint Peter's Community Hospital
Helena , Montana
Margaret R Pardee Memorial Hospital
Hendersonville , North Carolina
Hawaii Cancer Care Inc - Waterfront Plaza
Honolulu , Hawaii
Queen's Cancer Cenrer - POB I
Honolulu , Hawaii
Queen's Medical Center
Honolulu , Hawaii
Straub Clinic and Hospital
Honolulu , Hawaii
University of Hawaii Cancer Center
Honolulu , Hawaii
Hawaii Cancer Care Inc-Liliha
Honolulu , Hawaii
Queen's Cancer Center - Kuakini
Honolulu , Hawaii
The Cancer Center of Hawaii-Liliha
Honolulu , Hawaii
Kapiolani Medical Center for Women and Children
Honolulu , Hawaii
M D Anderson Cancer Center
Houston , Texas
Cancer Center of Kansas-Independence
Independence , Kansas
Swedish Cancer Institute-Issaquah
Issaquah , Washington
MU Health Care Goldschmidt Cancer Center
Jefferson City , Missouri
Freeman Health System
Joplin , Missouri
Mercy Hospital Joplin
Joplin , Missouri
West Michigan Cancer Center
Kalamazoo , Michigan
Logan Health Medical Center
Kalispell , Montana
University of Kansas Cancer Center-West
Kansas City , Kansas
University of Kansas Cancer Center
Kansas City , Kansas
University Health Truman Medical Center
Kansas City , Missouri
Kansas City Veterans Affairs Medical Center
Kansas City , Missouri
The University of Kansas Cancer Center-South
Kansas City , Missouri
University of Kansas Cancer Center - North
Kansas City , Missouri
Kadlec Clinic Hematology and Oncology
Kennewick , Washington
Greater Dayton Cancer Center
Kettering , Ohio
Kettering Medical Center
Kettering , Ohio
Illinois CancerCare-Kewanee Clinic
Kewanee , Illinois
Cancer Center of Kansas-Kingman
Kingman , Kansas
ECU Health Oncology Kinston
Kinston , North Carolina
Providence Regional Cancer System-Lacey
Lacey , Washington
Lawrence Memorial Hospital
Lawrence , Kansas
University of Kansas Cancer Center - Lee's Summit
Lee's Summit , Missouri
Cancer Center of Kansas-Liberal
Liberal , Kansas
Wilcox Memorial Hospital and Kauai Medical Clinic
Lihue , Hawaii
PeaceHealth Saint John Medical Center
Longview , Washington
Los Angeles General Medical Center
Los Angeles , California
USC / Norris Comprehensive Cancer Center
Los Angeles , California
Illinois CancerCare-Macomb
Macomb , Illinois
Cancer Center of Kansas-Manhattan
Manhattan , Kansas
Carle Physician Group-Mattoon/Charleston
Mattoon , Illinois
Loyola University Medical Center
Maywood , Illinois
Cancer Center of Kansas - McPherson
McPherson , Kansas
Baptist Memorial Hospital and Cancer Center-Memphis
Memphis , Tennessee
Mercy Cancer Center
Merced , California
Saint Luke's Cancer Institute - Meridian
Meridian , Idaho
Dayton Physicians LLC-Signal Point
Middletown , Ohio
Saint Patrick Hospital - Community Hospital
Missoula , Montana
Community Medical Center
Missoula , Montana
SSM Health Good Samaritan
Mount Vernon , Illinois
Trinity Health Muskegon Hospital
Muskegon , Michigan
Saint Luke's Cancer Institute - Nampa
Nampa , Idaho
Yale University
New Haven , Connecticut
Providence Newberg Medical Center
Newberg , Oregon
Cancer Center of Kansas - Newton
Newton , Kansas
Corewell Health Lakeland Hospitals - Niles Hospital
Niles , Michigan
Cancer Care Center of O'Fallon
O'Fallon , Illinois
University of Oklahoma Health Sciences Center
Oklahoma City , Oklahoma
The University of Kansas Cancer Center - Olathe
Olathe , Kansas
Providence Willamette Falls Medical Center
Oregon City , Oregon
Illinois CancerCare-Ottawa Clinic
Ottawa , Illinois
University of Kansas Cancer Center-Overland Park
Overland Park , Kansas
Cancer Center of Kansas - Parsons
Parsons , Kansas
Illinois CancerCare-Pekin
Pekin , Illinois
OSF Saint Francis Radiation Oncology at Pekin
Pekin , Illinois
Illinois CancerCare-Peoria
Peoria , Illinois
OSF Saint Francis Radiation Oncology at Peoria Cancer Center
Peoria , Illinois
Methodist Medical Center of Illinois
Peoria , Illinois
OSF Saint Francis Medical Center
Peoria , Illinois
Illinois CancerCare-Peru
Peru , Illinois
Valley Radiation Oncology
Peru , Illinois
FirstHealth of the Carolinas-Moore Regional Hospital
Pinehurst , North Carolina
Mercy Hospital Pittsburg
Pittsburg , Kansas
Providence Portland Medical Center
Portland , Oregon
Providence Saint Vincent Medical Center
Portland , Oregon
Kootenai Clinic Cancer Services - Post Falls
Post Falls , Idaho
Cancer Center of Kansas - Pratt
Pratt , Kansas
Illinois CancerCare-Princeton
Princeton , Illinois
Penn State Health Saint Joseph Medical Center
Reading , Pennsylvania
Corewell Health Reed City Hospital
Reed City , Michigan
Reid Health
Richmond , Indiana
Phelps Health Delbert Day Cancer Institute
Rolla , Missouri
University of California Davis Comprehensive Cancer Center
Sacramento , California
Corewell Health Lakeland Hospitals - Marie Yeager Cancer Center
Saint Joseph , Michigan
Corewell Health Lakeland Hospitals - Saint Joseph Hospital
Saint Joseph , Michigan
Sainte Genevieve County Memorial Hospital
Sainte Genevieve , Missouri
Cancer Center of Kansas - Salina
Salina , Kansas
Salina Regional Health Center
Salina , Kansas
Audie L Murphy VA Hospital
San Antonio , Texas
Cancer Therapy and Research Center at The UT Health Science Center at San Antonio
San Antonio , Texas
University Hospital
San Antonio , Texas
University of Texas Health Science Center at San Antonio
San Antonio , Texas
Kootenai Clinic Cancer Services - Sandpoint
Sandpoint , Idaho
Pacific Gynecology Specialists
Seattle , Washington
Swedish Medical Center-Ballard Campus
Seattle , Washington
Kaiser Permanente Washington
Seattle , Washington
Swedish Medical Center-Cherry Hill
Seattle , Washington
Swedish Medical Center-First Hill
Seattle , Washington
Providence Regional Cancer System-Shelton
Shelton , Washington
Welch Cancer Center
Sheridan , Wyoming
Dayton Physicians LLC-Wilson
Sidney , Ohio
Siouxland Regional Cancer Center
Sioux City , Iowa
Sanford Cancer Center Oncology Clinic
Sioux Falls , South Dakota
Sanford USD Medical Center - Sioux Falls
Sioux Falls , South Dakota
Baptist Memorial Hospital and Cancer Center-Desoto
Southhaven , Mississippi
MultiCare Deaconess Cancer and Blood Specialty Center - Downtown
Spokane , Washington
MultiCare Deaconess Cancer and Blood Specialty Center - North
Spokane , Washington
MultiCare Deaconess Cancer and Blood Specialty Center - Valley
Spokane Valley , Washington
Springfield Regional Cancer Center
Springfield , Ohio
Springfield Regional Medical Center
Springfield , Ohio
Central Illinois Hematology Oncology Center
Springfield , Illinois
Southern Illinois University School of Medicine
Springfield , Illinois
Springfield Clinic
Springfield , Illinois
Springfield Memorial Hospital
Springfield , Illinois
Mercy Hospital Springfield
Springfield , Missouri
CoxHealth South Hospital
Springfield , Missouri
Mercy Infusion Center - Chippewa
St Louis , Missouri
Missouri Baptist Medical Center
St Louis , Missouri
Mercy Hospital Saint Louis
St Louis , Missouri
Missouri Baptist Sullivan Hospital
Sullivan , Missouri
BJC Outpatient Center at Sunset Hills
Sunset Hills , Missouri
Southwest Illinois Health Services LLP
Swansea , Illinois
University of Kansas Health System Saint Francis Campus
Topeka , Kansas
Munson Medical Center
Traverse City , Michigan
Dayton Physicians LLC - Troy
Troy , Ohio
Upper Valley Medical Center
Troy , Ohio
Banner University Medical Center - Tucson
Tucson , Arizona
University of Arizona Cancer Center-North Campus
Tucson , Arizona
Saint Luke's Cancer Institute - Twin Falls
Twin Falls , Idaho
Carle Cancer Center
Urbana , Illinois
The Carle Foundation Hospital
Urbana , Illinois
PeaceHealth Southwest Medical Center
Vancouver , Washington
Providence Saint Mary Regional Cancer Center
Walla Walla , Washington
Mercy Hospital Washington
Washington , Missouri
Cancer Center of Kansas - Wellington
Wellington , Kansas
University of Kansas Hospital-Westwood Cancer Center
Westwood , Kansas
Associates In Womens Health
Wichita , Kansas
Cancer Center of Kansas-Wichita Medical Arts Tower
БГ