Breast-Conserving Surgery and Radiation Therapy in Patients With Multiple Ipsilateral Breast Cancer

Sponsor

Alliance for Clinical Trials in Oncology (Other)

Overall Status

Active, not recruiting

CT.gov ID

NCT01556243

Collaborator

National Cancer Institute (NCI) (NIH)

270

Enrollment

350

Locations

Arm

0.8

Patients Per Site

Study Details

Study Description

Brief Summary

RATIONALE: Breast-conserving surgery is a less invasive type of surgery for breast cancer and may have fewer side effects and improve recovery. Radiation therapy uses high-energy x rays to kill tumor cells. Giving radiation therapy after surgery may kill any tumor cells that remain after surgery.

PURPOSE: This phase II trial studies how well breast-conserving surgery and radiation therapy work in treating patients with multiple ipsilateral breast cancer

Condition or Disease	Intervention/Treatment	Phase
Breast Cancer	Procedure: therapeutic conventional surgery Radiation: whole breast irradiation	Phase 2

Detailed Description

OBJECTIVES:

Primary

To assess the local recurrence (LR) rate with breast-conservation in patients with multiple ipsilateral primary breast cancer (MIBC).

Secondary

To examine the conversion rate to mastectomy secondary to persistent positive margins; poor cosmesis within the first year of attempting breast-conservation surgery (BCS) or inability to satisfy the radiation dose constraints on the boost to the lumpectomy bed of each site of disease.
To assess whether patients who did not undergo re-excision for close margins (< 2 mm) have a higher local recurrence (LR) rate than patients for whom negative margins were achieved.
To assess patient's perception of cosmesis and incidence of breast lymphedema.
To assess incidence of breast lymphedema
To examine the type and severity of adverse effects of breast conserving surgery and radiation for women with multiple ipsilateral primary breast cancer (MIBC).
To examine the radiation-related side effects of whole-breast radiation with a boost to 1 large or > 1 lumpectomy site.

OUTLINE: This is a multicenter study.

Patients undergo breast-conserving surgery (BCS) with all lesions resected to negative margins using 1 lumpectomy or 2-3 separate lumpectomy incisions at the discretion of the surgeon. Patients receive adjuvant chemotherapy and/or endocrine therapy at the discretion of the treating medical oncologist based on tumor characteristics.

Study Design

Study Type:

Interventional

Actual Enrollment :

270 participants

Allocation:

N/A

Intervention Model:

Single Group Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

Impact of Breast Conservation Surgery on Surgical Outcomes and Cosmesis in Patients With Multiple Ipsilateral Breast Cancers (MIBC)

Study Start Date :

Jul 1, 2012

Actual Primary Completion Date :

Jun 1, 2022

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Breast conservation surgery and radiation therapy Patients undergo breast conserving surgery. Patients receive adjuvant chemotherapy at the physician's discretion. Patients receiving chemotherapy will start treatment within 12 weeks following surgery. Patients receive radiation therapy within 8 weeks following the last dose of chemotherapy or within 10 weeks following surgery if not receiving chemotherapy. Patients receive endocrine therapy at the physician's discretion. Patient observation will occur every 6 months until 5 years after the end of radiation therapy.	Procedure: therapeutic conventional surgery Radiation: whole breast irradiation

Arm

Intervention/Treatment

Experimental: Breast conservation surgery and radiation therapy

Patients undergo breast conserving surgery. Patients receive adjuvant chemotherapy at the physician's discretion. Patients receiving chemotherapy will start treatment within 12 weeks following surgery. Patients receive radiation therapy within 8 weeks following the last dose of chemotherapy or within 10 weeks following surgery if not receiving chemotherapy. Patients receive endocrine therapy at the physician's discretion. Patient observation will occur every 6 months until 5 years after the end of radiation therapy.

Procedure: therapeutic conventional surgery

Radiation: whole breast irradiation

Outcome Measures

Primary Outcome Measures

Local recurrence defined as histologic evidence of ductal carcinoma in situ or invasive breast cancer in the ipsilateral breast or chest wall assessed up to 5 years [Up to 5 years post-treatment]

Secondary Outcome Measures

Conversion rate to mastectomy secondary to persistent positive margins assessed [Up to 5 years post-treatment]
Type and severity of adverse effects of breast-conserving surgery and radiation as assessed by the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 [Up to 30 days post-treatment]
Radiation-related side effects of whole-breast radiation with a boost to 1 large or > 1 lumpectomy site as assessed by NCI CTCAE version 4.0 [Up to 30 days post-treatment]
Patient's perception of cosmesis assessed up to 24 months after WBI using the BREAST-Q© scoring module [Up to 2 years post-treatment]

Eligibility Criteria

Criteria

Ages Eligible for Study:

40 Years and Older

Sexes Eligible for Study:

Female

Accepts Healthy Volunteers:

Registration Inclusion Criteria:

Age ≥ 40 years per National Comprehensive Cancer Network (NCCN) recommendations for breast conservation.
Life Expectancy of at least 5 years, excluding diagnosis of breast cancer (Comorbid conditions should be taken into consideration, but breast cancer diagnosis is not a consideration)
Female Gender - Men are excluded from this study. Male breast cancer is a rare event.

Men are rarely candidates for breast conservation surgery due to small breast size. Men are less likely to be candidates for breast conservation surgery if found to have MIBC.

Foci of Breast Cancer

4.1 Upon clinical exam and pre-operative imaging by mammogram +/- MRI, two or three foci of biopsy proven breast cancer separated by > 2 cm of normal breast tissue.

4.2 Foci must include at least one focus of invasive breast carcinoma with another focus of either invasive breast carcinoma or ductal carcinoma in situ (DCIS).

No more than 2 quadrants with biopsy proven breast cancer.

4.3 Note: The shortest distance between lesions must be reported on mammogram +/- MRI and eligibility criteria must be met on both, if both are obtained.

4.4 Note: Patient is eligible for study if lesion is not visualized on all imaging modalities (i.e., any of the lesion(s) is/are visualized on MRI but not on mammogram OR visualized on mammogram but not on MRI).

4.5 Ultrasound cannot be used to determine patient eligibility; eligibility to be determined by bilateral mammogram +/- MRI only.

4.6 Fine needle aspirate of the second or third lesion to document malignancy is allowed if the first focus is shown to be invasive by core needle biopsy.

4.7 Patient may remain on study if, upon pathological assessment, two or three lesions identified on pre-operative imaging represent one contiguous lesion.

Patients may be registered AFTER surgery and PRIOR TO radiation therapy if either of the criteria is met:

5.1 An area of atypia > 2cm from the index lesion excised at the time of cancer operation is upgraded to DCIS or invasive carcinoma thereby identifying MIBC. OR

5.2 Patient underwent resection of two or three foci of malignancy by breast conservation surgery with a minimum of one invasive focus of breast cancer and a minimum of 2 cm of normal breast tissue between the lesions on final pathology.

Mammogram Imaging - Bilateral mammogram ≤ 90 days prior to date of surgery.

6.1 Note: For patients undergoing more than 1 breast operation, this is the date of the first breast surgery for breast cancer treatment.

Staging of Cancer - cN0 or cN1 disease
ECOG Performance Status (PS) - 0, 1, or 2.
Ability to Complete Questionnaires - Ability to complete questionnaire(s) by themselves or with assistance
Ability to Provide Written Informed Consent
Willing to Return to Enrolling Institution - Willing to return to enrolling institution for follow-up during the Active Monitoring Phase (the active treatment and observation portions) of the study. Patients are encouraged to return to the enrolling institution; however, patients may receive radiation therapy at a different institution other than the enrolling institution.

Registration Exclusion Criteria:

Pregnancy, Nursing and Requirement for Contraception - Pregnant women, nursing women and women of childbearing potential who are unwilling to employ adequate contraception (as determined by the treating physician) are excluded from participation.

This study involves radiation therapy (WBI) that has known genotoxic, mutagenic and teratogenic effects.

Size of Single Focus of Disease on Preoperative Imaging - Largest single focus of disease > 5 centimeters by either mammogram or MRI or both. Note: Measurement of the largest single focus should include any satellite lesions within 1 centimeter of the index lesion.
Prior Staging Procedure - Surgical axillary staging procedure prior to first definitive breast operation. Note: FNA or core needle biopsy of axillary node is permitted.
Evidence of Metastatic Disease - Clinical or radiographic evidence of metastatic disease
Prior History of Breast Cancer - Prior history of ipsilateral breast cancer [DCIS, LCIS (lobular cancer in situ) or invasive]
Staging of Cancer - cNX, cN2, or cN3 disease
Breast Implants - Breast implants at time of diagnosis. Note: Patients who have had implants previously removed prior to diagnosis are eligible.
Systemic Illnesses or Concurrent Disease - Co-morbid systemic illnesses or other severe concurrent disease which, in the judgment of the investigator, would interfere significantly with whole breast irradiation (such as connective tissue disorders, lupus, scleroderma).
Uncontrolled Intercurrent Illness - 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.
Bilateral Breast Cancer - Prior or current LCIS, DCIS or invasive breast cancer in the opposite breast (i.e., bilateral disease is not allowed).
Disallowed Prior Treatments - Treatment including radiation therapy, chemotherapy, biotherapy, hormonal therapy for this cancer prior to surgery (i.e., any neoadjuvant chemotherapy or endocrine therapy is not allowed). Patients who undergo surgical resection with breast conservation and then are treated with adjuvant systemic therapy are eligible to enroll prior to the start of radiotherapy.
Partial Breast Radiation - Planned partial breast radiation.
Known BRCA Mutations - Patients with known BRCA mutations. Patients who are not tested or whose testing result is not returned at the time of registration are not excluded from registering to this study.
Other Active Malignancies - Other active malignancy ≤ 5 years prior to registration.

14.1 Exceptions: Non-melanotic skin cancer or carcinoma-in-situ of the cervix.

14.2 Note: If there is a history of prior malignancy, they must not be receiving other specific treatment for their cancer.

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	CHI Saint Vincent Cancer Center Hot Springs	Hot Springs	Arkansas	United States	71913
2	Epic Care-Dublin	Dublin	California	United States	94568
3	Bay Area Breast Surgeons, Incorporated	Emeryville	California	United States	94608
4	Epic Care Partners in Cancer Care	Emeryville	California	United States	94608
5	UC San Diego Moores Cancer Center	La Jolla	California	United States	92093
6	Cedars Sinai Medical Center	Los Angeles	California	United States	90048
7	Cedars-Sinai Medical Center	Los Angeles	California	United States	90048
8	Contra Costa Regional Medical Center	Martinez	California	United States	94553
9	Alta Bates Summit Medical Center-Summit Campus	Oakland	California	United States	94609
10	Bay Area Tumor Institute	Oakland	California	United States	94609
11	Stanford Cancer Institute	Palo Alto	California	United States	94304
12	Naval Medical Center-San Diego	San Diego	California	United States	92134-3202
13	University of Colorado Cancer Center-Anschutz Cancer Pavilion	Aurora	Colorado	United States	80045
14	Catholic Health Initiatives NCORP	Englewood	Colorado	United States	80112
15	Smilow Cancer Hospital Care Center at Saint Francis	Hartford	Connecticut	United States	06105
16	Beebe Medical Center	Lewes	Delaware	United States	19958
17	Christiana Gynecologic Oncology LLC	Newark	Delaware	United States	19713
18	Delaware Clinical and Laboratory Physicians PA	Newark	Delaware	United States	19713
19	Helen F. Graham Cancer Center	Newark	Delaware	United States	19713
20	Medical Oncology Hematology Consultants PA	Newark	Delaware	United States	19713
21	Regional Hematology and Oncology PA	Newark	Delaware	United States	19713
22	Christiana Care Health System-Christiana Hospital	Newark	Delaware	United States	19718
23	Beebe Health Campus	Rehoboth Beach	Delaware	United States	19971
24	Nanticoke Memorial Hospital	Seaford	Delaware	United States	19973
25	Christiana Care Health System-Wilmington Hospital	Wilmington	Delaware	United States	19801
26	Morton Plant Hospital	Clearwater	Florida	United States	33756
27	Mount Sinai Medical Center	Miami Beach	Florida	United States	33140
28	University of Miami Miller School of Medicine-Sylvester Cancer Center	Miami	Florida	United States	33136
29	Lewis Cancer and Research Pavilion at Saint Joseph's/Candler	Savannah	Georgia	United States	31405
30	Oncare Hawaii, Incorporated-Pali Momi	'Aiea	Hawaii	United States	96701
31	Pali Momi Medical Center	'Aiea	Hawaii	United States	96701
32	The Cancer Center of Hawaii-Leeward	'Ewa Beach	Hawaii	United States	96706
33	Oncare Hawaii Inc-POB II	Honolulu	Hawaii	United States	96813
34	Queen's Medical Center	Honolulu	Hawaii	United States	96813
35	Straub Clinic and Hospital	Honolulu	Hawaii	United States	96813
36	University of Hawaii Cancer Center	Honolulu	Hawaii	United States	96813
37	Kuakini Medical Center	Honolulu	Hawaii	United States	96817
38	OnCare Hawaii, Incorporated-Kuakini	Honolulu	Hawaii	United States	96817
39	OnCare Hawaii-Liliha	Honolulu	Hawaii	United States	96817
40	The Cancer Center of Hawaii-Liliha	Honolulu	Hawaii	United States	96817
41	Kapiolani Medical Center for Women and Children	Honolulu	Hawaii	United States	96826
42	Wilcox Memorial Hospital and Kauai Medical Clinic	Lihue	Hawaii	United States	96766
43	Saint Alphonsus Cancer Care Center-Boise	Boise	Idaho	United States	83706
44	Kootenai Medical Center	Coeur d'Alene	Idaho	United States	83814
45	Kootenai Cancer Center	Post Falls	Idaho	United States	83854
46	Kootenai Cancer Clinic	Sandpoint	Idaho	United States	83864
47	Saint Joseph Medical Center	Bloomington	Illinois	United States	61701
48	Illinois CancerCare-Bloomington	Bloomington	Illinois	United States	61704
49	Illinois CancerCare-Canton	Canton	Illinois	United States	61520
50	Memorial Hospital of Carbondale	Carbondale	Illinois	United States	62902
51	Illinois CancerCare-Carthage	Carthage	Illinois	United States	62321
52	Centralia Oncology Clinic	Centralia	Illinois	United States	62801
53	University of Illinois	Chicago	Illinois	United States	60612
54	Cancer Care Specialists of Central Illinois	Decatur	Illinois	United States	62526
55	Decatur Memorial Hospital	Decatur	Illinois	United States	62526
56	Crossroads Cancer Center	Effingham	Illinois	United States	62401
57	Illinois CancerCare-Eureka	Eureka	Illinois	United States	61530
58	Illinois CancerCare-Galesburg	Galesburg	Illinois	United States	61401
59	Western Illinois Cancer Treatment Center	Galesburg	Illinois	United States	61401
60	Ingalls Memorial Hospital	Harvey	Illinois	United States	60426
61	Illinois CancerCare-Kewanee Clinic	Kewanee	Illinois	United States	61443
62	Illinois CancerCare-Macomb	Macomb	Illinois	United States	61455
63	Illinois CancerCare-Ottawa Clinic	Ottawa	Illinois	United States	61350
64	Radiation Oncology of Northern Illinois	Ottawa	Illinois	United States	61350
65	OSF Saint Francis Radiation Oncology at Pekin Cancer Treatment Center	Pekin	Illinois	United States	61554
66	Illinois CancerCare-Pekin	Pekin	Illinois	United States	61603
67	Methodist Medical Center of Illinois	Peoria	Illinois	United States	61603
68	Illinois CancerCare-Peoria	Peoria	Illinois	United States	61615
69	OSF Saint Francis Radiation Oncology at Peoria Cancer Center	Peoria	Illinois	United States	61615
70	OSF Saint Francis Medical Center	Peoria	Illinois	United States	61637
71	Illinois CancerCare-Peru	Peru	Illinois	United States	61354
72	Valley Radiation Oncology	Peru	Illinois	United States	61354
73	Illinois CancerCare-Princeton	Princeton	Illinois	United States	61356
74	Central Illinois Hematology Oncology Center	Springfield	Illinois	United States	62702
75	Southern Illinois University School of Medicine	Springfield	Illinois	United States	62702
76	Springfield Clinic	Springfield	Illinois	United States	62703
77	Memorial Medical Center	Springfield	Illinois	United States	62781
78	Cancer Care Specialists of Illinois-Swansea	Swansea	Illinois	United States	62226
79	IU Health West Hospital	Avon	Indiana	United States	46123
80	IU Health North Hospital	Carmel	Indiana	United States	46032
81	IU Health Central Indiana Cancer Centers-Fishers	Fishers	Indiana	United States	46037
82	Indiana University-Melvin and Bren Simon Cancer Center	Indianapolis	Indiana	United States	46202
83	IU Health Methodist Hospital	Indianapolis	Indiana	United States	46202
84	Sidney and Lois Eskenazi Hospital	Indianapolis	Indiana	United States	46202
85	Memorial Regional Cancer Center-Day Road	Mishawaka	Indiana	United States	46544
86	Saint Joseph Regional Medical Center-Mishawaka	Mishawaka	Indiana	United States	46545
87	Memorial Hospital of South Bend	South Bend	Indiana	United States	46601
88	Michiana Hematology Oncology PC-South Bend	South Bend	Indiana	United States	46601
89	Mary Greeley Medical Center	Ames	Iowa	United States	50010
90	McFarland Clinic PC-William R Bliss Cancer Center	Ames	Iowa	United States	50010
91	McFarland Clinic PC-Boone	Boone	Iowa	United States	50036
92	Medical Oncology and Hematology Associates-West Des Moines	Clive	Iowa	United States	50325
93	Mercy Cancer Center-West Lakes	Clive	Iowa	United States	50325
94	Alegent Health Mercy Hospital	Council Bluffs	Iowa	United States	51503
95	Greater Regional Medical Center	Creston	Iowa	United States	50801
96	Iowa Methodist Medical Center	Des Moines	Iowa	United States	50309
97	Iowa-Wide Oncology Research Coalition NCORP	Des Moines	Iowa	United States	50309
98	Medical Oncology and Hematology Associates-Des Moines	Des Moines	Iowa	United States	50309
99	Medical Oncology and Hematology Associates-Laurel	Des Moines	Iowa	United States	50314
100	Mercy Medical Center-Des Moines	Des Moines	Iowa	United States	50314
101	Iowa Lutheran Hospital	Des Moines	Iowa	United States	50316
102	McFarland Clinic PC-Trinity Cancer Center	Fort Dodge	Iowa	United States	50501
103	McFarland Clinic PC-Jefferson	Jefferson	Iowa	United States	50129
104	McFarland Clinic PC-Marshalltown	Marshalltown	Iowa	United States	50158
105	Mercy Medical Center-West Lakes	West Des Moines	Iowa	United States	50266
106	Methodist West Hospital	West Des Moines	Iowa	United States	50266
107	Menorah Medical Center	Overland Park	Kansas	United States	66209
108	Saint Luke's South Hospital	Overland Park	Kansas	United States	66213
109	Kansas City NCI Community Oncology Research Program	Prairie Village	Kansas	United States	66208
110	Flaget Memorial Hospital	Bardstown	Kentucky	United States	40004
111	Commonwealth Cancer Center-Corbin	Corbin	Kentucky	United States	40701
112	Saint Elizabeth Medical Center South	Edgewood	Kentucky	United States	41017
113	Saint Elizabeth-Fort Thomas	Fort Thomas	Kentucky	United States	41075
114	Saint Joseph Radiation Oncology Resource Center	Lexington	Kentucky	United States	40504
115	Saint Joseph Hospital East	Lexington	Kentucky	United States	40509
116	Jewish Hospital	Louisville	Kentucky	United States	40202
117	The James Graham Brown Cancer Center at University of Louisville	Louisville	Kentucky	United States	40202
118	Saints Mary and Elizabeth Hospital	Louisville	Kentucky	United States	40215
119	Jewish Hospital Medical Center Northeast	Louisville	Kentucky	United States	40245
120	Jewish Hospital Medical Center South	Shepherdsville	Kentucky	United States	40165
121	Eastern Maine Medical Center	Bangor	Maine	United States	04401
122	Eastern Maine Medical Center Cancer Care	Brewer	Maine	United States	04412
123	Sinai Hospital of Baltimore	Baltimore	Maryland	United States	21215
124	Saint Agnes Hospital	Baltimore	Maryland	United States	21229
125	Dana-Farber Cancer Institute	Boston	Massachusetts	United States	02115
126	Dana-Farber/Brigham and Women's Cancer Center at South Shore	South Weymouth	Massachusetts	United States	02190
127	Saint Joseph Mercy Hospital	Ann Arbor	Michigan	United States	48106
128	Bronson Battle Creek	Battle Creek	Michigan	United States	49017
129	Oakwood Hospital and Medical Center	Dearborn	Michigan	United States	48124
130	Wayne State University/Karmanos Cancer Institute	Detroit	Michigan	United States	48201
131	Saint John Hospital and Medical Center	Detroit	Michigan	United States	48236
132	Genesys Hurley Cancer Institute	Flint	Michigan	United States	48503
133	Hurley Medical Center	Flint	Michigan	United States	48503
134	Mercy Health Saint Mary's	Grand Rapids	Michigan	United States	49503
135	Spectrum Health at Butterworth Campus	Grand Rapids	Michigan	United States	49503
136	Allegiance Health	Jackson	Michigan	United States	49201
137	Borgess Medical Center	Kalamazoo	Michigan	United States	49001
138	Bronson Methodist Hospital	Kalamazoo	Michigan	United States	49007
139	West Michigan Cancer Center	Kalamazoo	Michigan	United States	49007
140	Sparrow Hospital	Lansing	Michigan	United States	48912
141	Saint Mary Mercy Hospital	Livonia	Michigan	United States	48154
142	Mercy Health Mercy Campus	Muskegon	Michigan	United States	49444
143	Saint Joseph Mercy Oakland	Pontiac	Michigan	United States	48341
144	William Beaumont Hospital-Royal Oak	Royal Oak	Michigan	United States	48073
145	Saint Mary's of Michigan	Saginaw	Michigan	United States	48601
146	Munson Medical Center	Traverse City	Michigan	United States	49684
147	William Beaumont Hospital-Troy	Troy	Michigan	United States	48098
148	Saint John Macomb-Oakland Hospital	Warren	Michigan	United States	48093
149	Fairview Ridges Hospital	Burnsville	Minnesota	United States	55337
150	Mercy Hospital	Coon Rapids	Minnesota	United States	55433
151	Fairview-Southdale Hospital	Edina	Minnesota	United States	55435
152	Unity Hospital	Fridley	Minnesota	United States	55432
153	Minnesota Oncology Hematology PA-Maplewood	Maplewood	Minnesota	United States	55109
154	Saint John's Hospital-Healtheast	Maplewood	Minnesota	United States	55109
155	Abbott-Northwestern Hospital	Minneapolis	Minnesota	United States	55407
156	Hennepin County Medical Center	Minneapolis	Minnesota	United States	55415
157	Health Partners Inc	Minneapolis	Minnesota	United States	55454
158	New Ulm Medical Center	New Ulm	Minnesota	United States	56073
159	North Memorial Medical Health Center	Robbinsdale	Minnesota	United States	55422
160	Mayo Clinic Cancer Center	Rochester	Minnesota	United States	55905
161	Coborn Cancer Center at Saint Cloud Hospital	Saint Cloud	Minnesota	United States	56303
162	Saint Cloud Hospital	Saint Cloud	Minnesota	United States	56303
163	Metro Minnesota Community Oncology Research Consortium	Saint Louis Park	Minnesota	United States	55416
164	Park Nicollet Clinic-Saint Louis Park	Saint Louis Park	Minnesota	United States	55416
165	Regions Hospital	Saint Paul	Minnesota	United States	55101
166	United Hospital	Saint Paul	Minnesota	United States	55102
167	Saint Francis Regional Medical Center	Shakopee	Minnesota	United States	55379
168	Lakeview Hospital	Stillwater	Minnesota	United States	55082
169	Ridgeview Medical Center	Waconia	Minnesota	United States	55387
170	Rice Memorial Hospital	Willmar	Minnesota	United States	56201
171	Minnesota Oncology and Hematology PA-Woodbury	Woodbury	Minnesota	United States	55125
172	Parkland Health Center-Bonne Terre	Bonne Terre	Missouri	United States	63628
173	Saint Francis Medical Center	Cape Girardeau	Missouri	United States	63703
174	Southeast Cancer Center	Cape Girardeau	Missouri	United States	63703
175	Centerpoint Medical Center LLC	Independence	Missouri	United States	64057
176	Capital Region Medical Center-Goldschmidt Cancer Center	Jefferson City	Missouri	United States	65109
177	Saint Luke's Hospital of Kansas City	Kansas City	Missouri	United States	64111
178	Heartland Hematology and Oncology Associates Incorporated	Kansas City	Missouri	United States	64118
179	Research Medical Center	Kansas City	Missouri	United States	64132
180	Saint Luke's East-Lee's Summit	Lee's Summit	Missouri	United States	64086
181	Liberty Radiation Oncology Center	Liberty	Missouri	United States	64068
182	Washington University School of Medicine	Saint Louis	Missouri	United States	63110
183	Missouri Baptist Medical Center	Saint Louis	Missouri	United States	63131
184	Sainte Genevieve County Memorial Hospital	Sainte Genevieve	Missouri	United States	63670
185	Missouri Baptist Sullivan Hospital	Sullivan	Missouri	United States	63080
186	Missouri Baptist Outpatient Center-Sunset Hills	Sunset Hills	Missouri	United States	63127
187	Montana Cancer Consortium NCORP	Billings	Montana	United States	59101
188	Saint Vincent Healthcare	Billings	Montana	United States	59101
189	Billings Clinic Cancer Center	Billings	Montana	United States	59107
190	Bozeman Deaconess Hospital	Bozeman	Montana	United States	59715
191	Saint James Community Hospital and Cancer Treatment Center	Butte	Montana	United States	59701
192	Benefis Healthcare-Sletten Cancer Institute	Great Falls	Montana	United States	59405
193	Saint Peter's Community Hospital	Helena	Montana	United States	59601
194	Kalispell Regional Medical Center	Kalispell	Montana	United States	59901
195	Community Medical Hospital	Missoula	Montana	United States	59801
196	Saint Patrick Hospital-Community Hospital	Missoula	Montana	United States	59802
197	CHI Health Saint Francis	Grand Island	Nebraska	United States	68803
198	Heartland Hematology and Oncology	Kearney	Nebraska	United States	68845
199	CHI Health Good Samaritan	Kearney	Nebraska	United States	68847
200	Saint Elizabeth Regional Medical Center	Lincoln	Nebraska	United States	68510
201	Alegent Health Immanuel Medical Center	Omaha	Nebraska	United States	68122
202	Hematology and Oncology Consultants PC	Omaha	Nebraska	United States	68122
203	Alegent Health Bergan Mercy Medical Center	Omaha	Nebraska	United States	68124
204	Alegent Health Lakeside Hospital	Omaha	Nebraska	United States	68130
205	Creighton University Medical Center	Omaha	Nebraska	United States	68131
206	Midlands Community Hospital	Papillion	Nebraska	United States	68046
207	Cancer and Blood Specialists-Henderson	Henderson	Nevada	United States	89052
208	Comprehensive Cancer Centers of Nevada-Henderson	Henderson	Nevada	United States	89052
209	Las Vegas Cancer Center-Henderson	Henderson	Nevada	United States	89052
210	21st Century Oncology-Henderson	Henderson	Nevada	United States	89074
211	Comprehensive Cancer Centers of Nevada-Southeast Henderson	Henderson	Nevada	United States	89074
212	University Medical Center of Southern Nevada	Las Vegas	Nevada	United States	89102
213	Cancer and Blood Specialists-Shadow	Las Vegas	Nevada	United States	89106
214	Nevada Cancer Research Foundation NCORP	Las Vegas	Nevada	United States	89106
215	Radiation Oncology Centers of Nevada Central	Las Vegas	Nevada	United States	89106
216	21st Century Oncology-Fort Apache	Las Vegas	Nevada	United States	89109
217	21st Century Oncology	Las Vegas	Nevada	United States	89109
218	HealthCare Partners Medical Group Oncology/Hematology-Maryland Parkway	Las Vegas	Nevada	United States	89109
219	HealthCare Partners Medical Group Oncology/Hematology-San Martin	Las Vegas	Nevada	United States	89113
220	Radiation Oncology Centers of Nevada Southeast	Las Vegas	Nevada	United States	89119
221	Cancer Therapy and Integrative Medicine	Las Vegas	Nevada	United States	89121
222	21st Century Oncology-Vegas Tenaya	Las Vegas	Nevada	United States	89128
223	Cancer and Blood Specialists-Tenaya	Las Vegas	Nevada	United States	89128
224	Comprehensive Cancer Centers of Nevada-Northwest	Las Vegas	Nevada	United States	89128
225	HealthCare Partners Medical Group Oncology/Hematology-Tenaya	Las Vegas	Nevada	United States	89128
226	Comprehensive Cancer Centers of Nevada-Summerlin	Las Vegas	Nevada	United States	89144
227	Cancer and Blood Specialists-Fort Apache	Las Vegas	Nevada	United States	89148
228	Comprehensive Cancer Centers of Nevada	Las Vegas	Nevada	United States	89148
229	Las Vegas Cancer Center-Medical Center	Las Vegas	Nevada	United States	89148
230	HealthCare Partners Medical Group Oncology/Hematology-Centennial Hills	Las Vegas	Nevada	United States	89149
231	Comprehensive Cancer Centers of Nevada-Central Valley	Las Vegas	Nevada	United States	89169
232	Dartmouth Hitchcock Medical Center	Lebanon	New Hampshire	United States	03756
233	Memorial Sloan Kettering Cancer Center-Basking Ridge	Basking Ridge	New Jersey	United States	07920
234	Saint Peter's University Hospital	New Brunswick	New Jersey	United States	08901
235	University of New Mexico Cancer Center	Albuquerque	New Mexico	United States	87102
236	Lovelace Women's Hospital	Albuquerque	New Mexico	United States	87109
237	Memorial Sloan Kettering Cancer Center-Commack	Commack	New York	United States	11725
238	Memorial Sloan Kettering Cancer Center-West Harrison	Harrison	New York	United States	10604
239	North Shore University Hospital	Manhasset	New York	United States	11030
240	North Shore-LIJ Health System/Center for Advanced Medicine	New Hyde Park	New York	United States	11040
241	Memorial Sloan Kettering Cancer Center	New York	New York	United States	10065
242	Vassar Brothers Medical Center	Poughkeepsie	New York	United States	12601
243	University of Rochester	Rochester	New York	United States	14642
244	Memorial Sloan Kettering Cancer Center-Rockville Centre	Rockville Centre	New York	United States	11570
245	Memorial Sloan Kettering Cancer Center-Sleepy Hollow	Sleepy Hollow	New York	United States	10591
246	Randolph Hospital	Asheboro	North Carolina	United States	27203
247	Carolinas Medical Center/Levine Cancer Institute	Charlotte	North Carolina	United States	28203
248	Levine Cancer Institute-Tryon	Charlotte	North Carolina	United States	28203
249	Novant Health Presbyterian Medical Center	Charlotte	North Carolina	United States	28204
250	Carolina Surgical Clinic of Charlotte PA	Charlotte	North Carolina	United States	28207
251	Oncology Specialists of Charlotte	Charlotte	North Carolina	United States	28207
252	Carolinas Medical Center/Levine Cancer Institute-Pineville	Charlotte	North Carolina	United States	28210
253	Carolinas Medical Center/Levine Cancer Institute-University	Charlotte	North Carolina	United States	28262
254	Southern Oncology Specialists-Charlotte	Charlotte	North Carolina	United States	28262
255	Levine Cancer Institute-Ballantyne	Charlotte	North Carolina	United States	28277
256	CaroMont Breast Surgical Specialists-Gastonia	Gastonia	North Carolina	United States	28054
257	CaroMont Regional Medical Center	Gastonia	North Carolina	United States	28054
258	Cone Health Cancer Center	Greensboro	North Carolina	United States	27403
259	Lake Norman Hematology Oncology Specialists-Huntersville	Huntersville	North Carolina	United States	28078
260	Southern Oncology Specialists-Huntersville	Huntersville	North Carolina	United States	28078
261	Matthews Radiation Oncology Center	Matthews	North Carolina	United States	28105
262	Novant Health Cancer Specialists-Matthews	Matthews	North Carolina	United States	28105
263	Carolinas HealthCare System Union	Monroe	North Carolina	United States	28112
264	Lake Norman Hematology Oncology Specialists-Mooresville	Mooresville	North Carolina	United States	28117
265	Annie Penn Memorial Hospital	Reidsville	North Carolina	United States	27320
266	Strecker Cancer Center-Belpre	Belpre	Ohio	United States	45714
267	Adena Regional Medical Center	Chillicothe	Ohio	United States	54601
268	The Christ Hospital	Cincinnati	Ohio	United States	45219
269	Good Samaritan Hospital-Cincinnati	Cincinnati	Ohio	United States	45220
270	Bethesda North Hospital	Cincinnati	Ohio	United States	45242
271	TriHealth Cancer Institute-Westside	Cincinnati	Ohio	United States	45247
272	TriHealth Cancer Institute-Anderson	Cincinnati	Ohio	United States	45255
273	University of Cincinnati	Cincinnati	Ohio	United States	45267
274	Mount Carmel East Hospital	Columbus	Ohio	United States	43213
275	Columbus Oncology and Hematology Associates Inc	Columbus	Ohio	United States	43214
276	Riverside Methodist Hospital	Columbus	Ohio	United States	43214
277	Columbus NCI Community Oncology Research Program	Columbus	Ohio	United States	43215
278	Grant Medical Center	Columbus	Ohio	United States	43215
279	The Mark H Zangmeister Center	Columbus	Ohio	United States	43219
280	Mount Carmel Health Center West	Columbus	Ohio	United States	43222
281	Doctors Hospital	Columbus	Ohio	United States	43228
282	Delaware Health Center-Grady Cancer Center	Delaware	Ohio	United States	43015
283	Delaware Radiation Oncology	Delaware	Ohio	United States	43015
284	Grady Memorial Hospital	Delaware	Ohio	United States	43015
285	Fairfield Medical Center	Lancaster	Ohio	United States	43130
286	OhioHealth MedCentral Hospital	Mansfield	Ohio	United States	44903
287	Marietta Memorial Hospital	Marietta	Ohio	United States	45750
288	OhioHealth Marion General Hospital	Marion	Ohio	United States	43302
289	Knox Community Hospital	Mount Vernon	Ohio	United States	43050
290	Licking Memorial Hospital	Newark	Ohio	United States	43055
291	Newark Radiation Oncology	Newark	Ohio	United States	43055
292	Southern Ohio Medical Center	Portsmouth	Ohio	United States	45662
293	Springfield Regional Medical Center	Springfield	Ohio	United States	45505
294	University Pointe	West Chester	Ohio	United States	45069
295	Saint Ann's Hospital	Westerville	Ohio	United States	43081
296	Genesis Healthcare System Cancer Care Center	Zanesville	Ohio	United States	43701
297	University of Oklahoma Health Sciences Center	Oklahoma City	Oklahoma	United States	73104
298	Mercy Hospital Oklahoma City	Oklahoma City	Oklahoma	United States	73120
299	Oregon Health and Science University	Portland	Oregon	United States	97239
300	Lehigh Valley Hospital-Cedar Crest	Allentown	Pennsylvania	United States	18103
301	Lehigh Valley Hospital-Muhlenberg	Bethlehem	Pennsylvania	United States	18017
302	Bryn Mawr Hospital	Bryn Mawr	Pennsylvania	United States	19010
303	University of Pittsburgh Cancer Institute (UPCI)	Pittsburgh	Pennsylvania	United States	15232
304	Lankenau Medical Center	Wynnewood	Pennsylvania	United States	19096
305	Roger Williams Medical Center	Providence	Rhode Island	United States	02908
306	Hilton Head Regional Medical Center	Hilton Head Island	South Carolina	United States	29926
307	Levine Cancer Institute-Rock Hill	Rock Hill	South Carolina	United States	29732
308	Lexington Medical Center	West Columbia	South Carolina	United States	29169
309	Avera Cancer Institute	Sioux Falls	South Dakota	United States	57105
310	Memorial Hospital	Chattanooga	Tennessee	United States	37404
311	Pulmonary Medicine Center of Chattanooga-Hixson	Hixson	Tennessee	United States	37343
312	Memorial GYN Plus	Ooltewah	Tennessee	United States	37363
313	Texas Tech University Health Sciences Center-Amarillo	Amarillo	Texas	United States	79106
314	Parkland Memorial Hospital	Dallas	Texas	United States	75235
315	UT Southwestern/Simmons Cancer Center-Dallas	Dallas	Texas	United States	75390
316	M. D. Anderson Cancer Center	Houston	Texas	United States	77030
317	The Methodist Hospital System	Houston	Texas	United States	77030
318	Doctor's Hospital of Laredo	Laredo	Texas	United States	78045
319	Huntsman Cancer Institute/University of Utah	Salt Lake City	Utah	United States	84112
320	Central Vermont Medical Center	Berlin	Vermont	United States	05602
321	University of Vermont College of Medicine	Burlington	Vermont	United States	05405
322	Norris Cotton Cancer Center-North	Saint Johnsbury	Vermont	United States	05819
323	Mary Washington Hospital	Fredericksburg	Virginia	United States	22401
324	Virginia Commonwealth University/Massey Cancer Center	Richmond	Virginia	United States	23298
325	Harrison HealthPartners Hematology and Oncology-Bremerton	Bremerton	Washington	United States	98310
326	Harrison Medical Center	Bremerton	Washington	United States	98310
327	Highline Medical Center-Main Campus	Burien	Washington	United States	98166
328	Saint Elizabeth Hospital	Enumclaw	Washington	United States	98022
329	Saint Francis Hospital	Federal Way	Washington	United States	98003
330	Saint Clare Hospital	Lakewood	Washington	United States	98499
331	Harrison HealthPartners Hematology and Oncology-Poulsbo	Poulsbo	Washington	United States	98370
332	Virginia Mason Medical Center	Seattle	Washington	United States	98101
333	Franciscan Research Center-Northwest Medical Plaza	Tacoma	Washington	United States	98405
334	Northwest Medical Specialties PLLC	Tacoma	Washington	United States	98405
335	Green Bay Oncology at Saint Vincent Hospital	Green Bay	Wisconsin	United States	54301
336	Saint Vincent Hospital	Green Bay	Wisconsin	United States	54301
337	Green Bay Oncology Limited at Saint Mary's Hospital	Green Bay	Wisconsin	United States	54303
338	Saint Mary's Hospital	Green Bay	Wisconsin	United States	54303
339	Aurora BayCare Medical Center	Green Bay	Wisconsin	United States	54311-6519
340	Gundersen Lutheran Medical Center	La Crosse	Wisconsin	United States	54601
341	Aurora Saint Luke's Medical Center	Milwaukee	Wisconsin	United States	53215
342	Froedtert and the Medical College of Wisconsin	Milwaukee	Wisconsin	United States	53226
343	Aurora Sinai Medical Center	Milwaukee	Wisconsin	United States	53233
344	Westfields Hospital/Cancer Center of Western Wisconsin	New Richmond	Wisconsin	United States	54017
345	Vince Lombardi Cancer Clinic-Oshkosh	Oshkosh	Wisconsin	United States	54904
346	Aurora Medical Center in Summit	Summit	Wisconsin	United States	53066
347	Aurora West Allis Medical Center	West Allis	Wisconsin	United States	53227
348	Big Horn Basin Cancer Center	Cody	Wyoming	United States	82414
349	Billings Clinic-Cody	Cody	Wyoming	United States	82414
350	Welch Cancer Center	Sheridan	Wyoming	United States	82801