S1415CD, Trial Assessing CSF Prescribing Effectiveness and Risk (TrACER)

Sponsor

Southwest Oncology Group (Other)

Overall Status

Completed

CT.gov ID

NCT02728596

Collaborator

National Cancer Institute (NCI) (NIH), Patient-Centered Outcomes Research Institute (Other)

3,960

Enrollment

160

Locations

Arms

58.2

Actual Duration (Months)

24.8

Patients Per Site

0.4

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

This randomized clinical trial studies prophylactic colony stimulating factor management in patients with breast, colorectal or non-small cell lung cancer receiving chemotherapy and with risk of developing febrile neutropenia. Patients receiving chemotherapy may develop febrile neutropenia. Febrile neutropenia is a condition that involves fever and a low number of neutrophils (a type of white blood cell) in the blood. Febrile neutropenia increases the risk of infection. Colony stimulating factors are medications sometimes given to patients receiving chemotherapy to prevent febrile neutropenia. Colony stimulating factors are given to patients based on guidelines. Some clinics have an automated system that helps doctors decide when to prescribe them when there is a high risk of developing febrile neutropenia. Gathering information about the use of an automated system to prescribe prophylactic colony stimulating factor may help doctors use colony stimulating factor when it is needed.

Condition or Disease	Intervention/Treatment	Phase
Febrile Neutropenia Stage 0 Breast Cancer Stage 0 Colorectal Cancer Stage 0 Non-Small Cell Lung Cancer Stage I Colorectal Cancer Stage IA Breast Cancer Stage IA Non-Small Cell Lung Carcinoma Stage IB Breast Cancer Stage IB Non-Small Cell Lung Carcinoma Stage IIA Breast Cancer Stage IIA Colorectal Cancer Stage IIA Non-Small Cell Lung Carcinoma Stage IIB Breast Cancer Stage IIB Colorectal Cancer Stage IIB Non-Small Cell Lung Carcinoma Stage IIC Colorectal Cancer Stage IIIA Breast Cancer Stage IIIA Colorectal Cancer Stage IIIA Non-Small Cell Lung Cancer Stage IIIB Breast Cancer Stage IIIB Colorectal Cancer Stage IIIB Non-Small Cell Lung Cancer Stage IIIC Breast Cancer Stage IIIC Colorectal Cancer Stage IV Breast Cancer Stage IV Non-Small Cell Lung Cancer Stage IVA Colorectal Cancer Stage IVB Colorectal Cancer	Other: Preventive Intervention Other: Quality-of-Life Assessment Other: Questionnaire Administration	N/A

Detailed Description

PRIMARY OBJECTIVES:

To compare the use of primary prophylactic colony stimulating factor (PP-CSF) according to recommended clinical practice guidelines among patients registered at intervention components versus usual care components.
To compare the rate of febrile neutropenia (FN) among patients registered at intervention components versus usual care components.
To compare the rate of FN among intermediate risk patients registered at intervention components by component treatment assignment (administer PP-CSF to intermediate risk patients versus not).

SECONDARY OBJECTIVES:

To compare the rate of FN among low-risk patients registered at intervention components versus usual care components.
To compare the FN-related health-related quality of life (HRQOL) among low-risk patients registered at intervention components versus usual care components.
To compare patient adherence to PP-CSF prescribing among patients registered at intervention components versus usual care components.
To compare patient knowledge of the indications for, efficacy of, and side effects associated with PP-CSF between the initiation and conclusion of the first cycle of myelosuppressive systemic therapy among patients registered at intervention components versus usual care components.
To compare the proportion of patients completing the initial systemic therapy regimen at planned duration and at planned dose intensity among patients registered at intervention components versus usual care components.
To compare antibiotic use both as prophylaxis and as treatment for FN among patients registered at intervention components versus usual care components.
To compare the rate of FN-related emergency department visits and hospitalizations among intermediate risk patients registered to Intervention components by component treatment assignment (administer PP-CSF to intermediate risk patients versus not).
To compare the FN-related health-related quality of life (HRQOL) among intermediate risk patients registered to intervention components by component treatment assignment (administer PP-CSF to intermediate risk patients versus not).
To compare overall survival among intermediate risk patients registered to intervention components by component treatment assignment (administer PP-CSF to intermediate risk patients versus not).

TERTIARY OBJECTIVES:

To characterize and descriptively report the differences among cohort components and the intervention and usual care components.
To evaluate the time to invasive recurrence in non-metastatic patients by component treatment assignment

OUTLINE: Patients are randomized to 1 of 4 clinic groups.

CLINIC GROUP 1 (CLINIC WITH AUTOMATED SYSTEM): Patients with a high risk of developing FN receive CSF based on the automated system recommendations. The automated system suggests that CSFs not be used for drugs that have a low risk of FN.

CLINIC GROUP 2 (CLINIC WITH NO AUTOMATED SYSTEM): Patients receive CSF based on clinical practice guidelines.

CLINIC GROUP 3 (CLINIC WITH AUTOMATED SYSTEM): Patients with a high or moderate risk of developing FN receive CSF based on the automated system recommendations. The automated system suggests that CSFs not be used for drugs that have a low risk of FN.

CLINIC GROUP 4 (CLINIC WITH AUTOMATED SYSTEM): Patients with a high risk of developing FN receive CSF based on the automated system recommendations. The automated system suggests that CSF not be used for drugs that have a moderate risk of FN.

After completion of study treatment, patients are followed up for 12 months.

Study Design

Study Type:

Interventional

Anticipated Enrollment :

3960 participants

Allocation:

Randomized

Intervention Model:

Parallel Assignment

Masking:

None (Open Label)

Primary Purpose:

Health Services Research

Official Title:

A Pragmatic Trial to Evaluate a Guideline-Based Colony Stimulating Factor Standing Order Intervention and to Determine the Effectiveness of Colony Stimulating Factor Use as a Prophylaxis for Patients Receiving Chemotherapy With Intermediate Risk for Febrile Neutropenia - Trial Assessing CSF Prescribing Effectiveness and Risk (TrACER)

Actual Study Start Date :

Oct 7, 2016

Actual Primary Completion Date :

Apr 30, 2021

Actual Study Completion Date :

Aug 12, 2021

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Clinic group 1 (clinic with automated system) Patients with a high risk of developing FN receive CSF based on the automated system recommendations. The automated system suggests that CSFs not be used for drugs that have a low risk of FN.	Other: Preventive Intervention Receive PP-CSF Other Names: PREVENTATIVE Prevention Prevention Measures Prophylaxis PRYLX Other: Quality-of-Life Assessment Ancillary studies Other Names: Quality of Life Assessment Other: Questionnaire Administration Ancillary studies
Experimental: Clinic group 2 (clinic with no automated system) Patients receive CSF based on clinical practice guidelines.	Other: Preventive Intervention Receive PP-CSF Other Names: PREVENTATIVE Prevention Prevention Measures Prophylaxis PRYLX Other: Quality-of-Life Assessment Ancillary studies Other Names: Quality of Life Assessment Other: Questionnaire Administration Ancillary studies
Experimental: Clinic group 3 (clinic with automated system) Patients with a high or moderate risk of developing FN receive CSF based on the automated system recommendations. The automated system suggests that CSFs not be used for drugs that have a low risk of FN.	Other: Preventive Intervention Receive PP-CSF Other Names: PREVENTATIVE Prevention Prevention Measures Prophylaxis PRYLX Other: Quality-of-Life Assessment Ancillary studies Other Names: Quality of Life Assessment Other: Questionnaire Administration Ancillary studies
Active Comparator: Clinic group 4 (clinic with automated system) Patients with a high risk of developing FN receive CSF based on the automated system recommendations. The automated system suggests that CSF not be used for drugs that have a moderate risk of FN.	Other: Preventive Intervention Receive PP-CSF Other Names: PREVENTATIVE Prevention Prevention Measures Prophylaxis PRYLX Other: Quality-of-Life Assessment Ancillary studies Other Names: Quality of Life Assessment Other: Questionnaire Administration Ancillary studies

Outcome Measures

Primary Outcome Measures

Change in FN-related HRQL (patient report) assessed using the Functional Assessment of Cancer Therapy -Febrile Neutropenia (FACT-N) [Baseline to up to 14 days]
A linear mixed effects model will be fit to assess the effect of the intervention on HRQL. Component-level characteristics, patient-level clinical and demographic variables will be adjusted.
Change in patient knowledge of PP-CSF benefits (patient report) [Baseline to up to 14 days (1 course)]
Linear mixed effects model with a time variable and an interaction between randomized group and time will be used to analyze change in the patient knowledge score. Random effects will be used to accommodate both the correlation among measures from the same patient as well as the correlation among patients from the same component. Component-level characteristics, patient-level clinical and demographic variables will be adjusted.
Change in patient knowledge of PP-CSF indications (patient report) [Baseline to up to 14 days]
Linear mixed effects model with a time variable and an interaction between randomized group and time will be used to analyze change in the patient knowledge score. Random effects will be used to accommodate both the correlation among measures from the same patient as well as the correlation among patients from the same component. Component-level characteristics, patient-level clinical and demographic variables will be adjusted.
Change in patient knowledge of PP-CSF out-of-pocket costs (patient report) [Baseline to up to 6 months]
Linear mixed effects model with a time variable and an interaction between randomized group and time will be used to analyze change in the patient knowledge score. Random effects will be used to accommodate both the correlation among measures from the same patient as well as the correlation among patients from the same component. Component-level characteristics, patient-level clinical and demographic variables will be adjusted.
Change in patient knowledge of PP-CSF risks (patient report) [Baseline to up to 14 days (1 course)]
Linear mixed effects model with a time variable and an interaction between randomized group and time will be used to analyze change in the patient knowledge score. Random effects will be used to accommodate both the correlation among measures from the same patient as well as the correlation among patients from the same component. Component-level characteristics, patient-level clinical and demographic variables will be adjusted.
Incidence of febrile neutropenia (clinical) [Within 14 days after the completion of first course of therapy]
Graded according to the National Cancer Institute Common Toxicity Criteria version 4.0.
Incidence of febrile neutropenia (clinical) [Within 6 months]
Graded according to the National Cancer Institute Common Toxicity Criteria version 4.0.
Overall survival (clinical) [Time from date of registration to date of death due to any cause, assessed up to 12 months]
A Cox proportional hazards model will be used to model survival. Component-level characteristics, patient-level clinical and demographic variables will be adjusted. A separate analysis of cause-specific survival to address FN-related deaths will also be conducted.
Patient adherence to PP-CSF prescription (clinical and patient report) [Within 14 days after the completion of first course of therapy]
For the home and clinic settings, separate mixed effects logistic models will be used to assess the effect of the intervention on adherence to PP-CSF orders, treating adherence after the start of the study. Component-level characteristics, patient-level clinical and demographic variables will be adjusted.
Prophylactic and FN-related antibiotic use (clinical) [Within 30 days of therapy]
Prophylactic and FN-related antibiotic use will be measured as total number of antibiotic agents used and duration of antibiotic use. A linear mixed effects model will be fit to assess the effect of the intervention on duration of antibiotics use with number of days. Mixed effects Poisson models will be used to assess the effect of the intervention on total number of antibiotics agents used. Three separate models will be fit, with the following outcomes: (i) the number of times antibiotics were used as prophylaxis, (ii) the number of times antibiotics were used as treatment for FN, and (iii) t
Proportion completing initial systemic therapy regimen: a) at planned duration and b) at planned dose intensity (clinical) [Up to 12 months]
Two separate mixed effects logistic models will be used to assess the effect of the intervention on completion of the initial systemic therapy regimen (i) at planned duration and (ii) at planned dose intensity. Component-level characteristics, patient-level clinical and demographic variables will be adjusted.
Rate of CSF prescribing as primary prophylaxis (clinical) [Time from initiation of granulocyte CSFs during the first cycle of myelosuppressive systemic therapy, given 24 to 72 hours after cessation of systemic therapy, assessed up to 12 months]
PP-CSF use is observed and reported. Separate mixed effects logistic models will be fit to assess the effect of the intervention on PP-CSF use.
Rate of FN-related emergency department (ED) visits and hospitalizations (clinical) [At 6 months]
A mixed effects Poisson model will be used to assess the effect of the intervention on FN-related ED visits and hospitalizations. Robust variance estimation will be used to relax the strong assumptions about the variance made by Poisson regression. If a large number of zero counts is observed, then zero-inflated Poisson regression will be used.

Other Outcome Measures

Cancer relapse (clinical) only to patients with local or regional disease treated with curative intent [Time from registration to documented invasive local or regional recurrence, assessed up to 12 months]
Analysis will be exploratory and comparative.

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years and Older

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

Patients must have a current diagnosis of breast cancer, non-small cell lung cancer, or colorectal cancer; the current diagnosis may be an initial diagnosis or recurrence and/or progression of previously diagnosed disease; cancer may be metastatic or non-metastatic
Patients must be registered prior to or on the same day as their first cycle of chemotherapy for their current disease and stage 9or disease setting).
Patients must not have had any systemic therapy (chemotherapy or combination regimens) in the 180 days just prior to registration. Prior biologic therapy, immunotherapy, tyrosine kinase inhibitors, and hormonal therapy are allowed.
Patients must be planning to receive one of the study-allowed regimens as their initial treatment for their current disease; myelosuppressive therapy must follow the standard regimen, although a dose reduction of up to 10% is permitted. This treatment may be neoadjuvant or adjuvant chemotherapy.
Patients must not be receiving or planning to receive concurrent radiation during systemic treatment.
Patients must not have any known contraindication to CSFs prior to registration, including prior hypersensitivity to Escherichia coli-derived proteins, filgrastim, pegfilgrastim, or tbo-filgrastim
Patients must be able to understand and provide information for the patient-completed study forms in either English or Spanish
Patients may have had a prior malignancy
Patients must not be participating or plan to participate in other clinical trials that involve investigational systemic cancer treatments or investigational uses of CSF during their first 6 months after registration
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

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	Baptist Memorial Hospital and Fowler Family Cancer Center - Jonesboro	Jonesboro	Arkansas	United States	72401
2	NEA Baptist Memorial Hospital	Jonesboro	Arkansas	United States	72401
3	Contra Costa Regional Medical Center	Martinez	California	United States	94553-3156
4	Augusta University Medical Center	Augusta	Georgia	United States	30912
5	Lewis Cancer and Research Pavilion at Saint Joseph's/Candler	Savannah	Georgia	United States	31405
6	Queen's Medical Center	Honolulu	Hawaii	United States	96813
7	Tripler Army Medical Center	Honolulu	Hawaii	United States	96859
8	Saint Alphonsus Cancer Care Center-Boise	Boise	Idaho	United States	83706
9	Saint Luke's Mountain States Tumor Institute	Boise	Idaho	United States	83712
10	Saint Luke's Mountain States Tumor Institute - Fruitland	Fruitland	Idaho	United States	83619
11	Saint Luke's Mountain States Tumor Institute - Meridian	Meridian	Idaho	United States	83642
12	Saint Luke's Mountain States Tumor Institute - Nampa	Nampa	Idaho	United States	83686
13	Saint Luke's Mountain States Tumor Institute-Twin Falls	Twin Falls	Idaho	United States	83301
14	Illinois CancerCare-Bloomington	Bloomington	Illinois	United States	61704
15	Illinois CancerCare-Canton	Canton	Illinois	United States	61520
16	Illinois CancerCare-Carthage	Carthage	Illinois	United States	62321
17	Centralia Oncology Clinic	Centralia	Illinois	United States	62801
18	John H Stroger Jr Hospital of Cook County	Chicago	Illinois	United States	60612
19	Carle on Vermilion	Danville	Illinois	United States	61832
20	Cancer Care Specialists of Illinois - Decatur	Decatur	Illinois	United States	62526
21	Carle Physician Group-Effingham	Effingham	Illinois	United States	62401
22	Crossroads Cancer Center	Effingham	Illinois	United States	62401
23	Illinois CancerCare-Eureka	Eureka	Illinois	United States	61530
24	Illinois CancerCare-Galesburg	Galesburg	Illinois	United States	61401
25	Illinois CancerCare-Kewanee Clinic	Kewanee	Illinois	United States	61443
26	Illinois CancerCare-Macomb	Macomb	Illinois	United States	61455
27	Carle Physician Group-Mattoon/Charleston	Mattoon	Illinois	United States	61938
28	Illinois CancerCare-Ottawa Clinic	Ottawa	Illinois	United States	61350
29	Illinois CancerCare-Pekin	Pekin	Illinois	United States	61554
30	Illinois CancerCare-Peoria	Peoria	Illinois	United States	61615
31	Illinois CancerCare-Peru	Peru	Illinois	United States	61354
32	Illinois CancerCare-Princeton	Princeton	Illinois	United States	61356
33	Cancer Care Specialists of Illinois-Swansea	Swansea	Illinois	United States	62226
34	Carle Cancer Center	Urbana	Illinois	United States	61801
35	Oncology Associates at Mercy Medical Center	Cedar Rapids	Iowa	United States	52403
36	Medical Oncology and Hematology Associates-Des Moines	Des Moines	Iowa	United States	50309
37	Cancer Center of Kansas - Chanute	Chanute	Kansas	United States	66720
38	Cancer Center of Kansas - Dodge City	Dodge City	Kansas	United States	67801
39	Cancer Center of Kansas - El Dorado	El Dorado	Kansas	United States	67042
40	Cancer Center of Kansas - Fort Scott	Fort Scott	Kansas	United States	66701
41	Cancer Center of Kansas-Independence	Independence	Kansas	United States	67301
42	Cancer Center of Kansas-Kingman	Kingman	Kansas	United States	67068
43	Cancer Center of Kansas-Liberal	Liberal	Kansas	United States	67905
44	Cancer Center of Kansas - Newton	Newton	Kansas	United States	67114
45	Menorah Medical Center	Overland Park	Kansas	United States	66209
46	Cancer Center of Kansas - Parsons	Parsons	Kansas	United States	67357
47	Cancer Center of Kansas - Pratt	Pratt	Kansas	United States	67124
48	Cancer Center of Kansas - Salina	Salina	Kansas	United States	67401
49	Cancer Center of Kansas - Wellington	Wellington	Kansas	United States	67152
50	Cancer Center of Kansas-Wichita Medical Arts Tower	Wichita	Kansas	United States	67208
51	Cancer Center of Kansas - Wichita	Wichita	Kansas	United States	67214
52	Cancer Center of Kansas - Winfield	Winfield	Kansas	United States	67156
53	Louisiana State University Health Science Center	New Orleans	Louisiana	United States	70112
54	University Medical Center New Orleans	New Orleans	Louisiana	United States	70112
55	Louisiana State University Health Sciences Center Shreveport	Shreveport	Louisiana	United States	71103
56	Saint Joseph Mercy Hospital	Ann Arbor	Michigan	United States	48106
57	Saint Joseph Mercy Brighton	Brighton	Michigan	United States	48114
58	Saint Joseph Mercy Canton	Canton	Michigan	United States	48188
59	Saint Joseph Mercy Chelsea	Chelsea	Michigan	United States	48118
60	Ascension Saint John Hospital	Detroit	Michigan	United States	48236
61	West Michigan Cancer Center	Kalamazoo	Michigan	United States	49007
62	Saint Mary Mercy Hospital	Livonia	Michigan	United States	48154
63	William Beaumont Hospital-Royal Oak	Royal Oak	Michigan	United States	48073
64	William Beaumont Hospital - Troy	Troy	Michigan	United States	48085
65	Saint John Macomb-Oakland Hospital	Warren	Michigan	United States	48093
66	Sanford Joe Lueken Cancer Center	Bemidji	Minnesota	United States	56601
67	Essentia Health Saint Joseph's Medical Center	Brainerd	Minnesota	United States	56401
68	Essentia Health Cancer Center	Duluth	Minnesota	United States	55805
69	Sanford Thief River Falls Medical Center	Thief River Falls	Minnesota	United States	56701
70	Sanford Cancer Center Worthington	Worthington	Minnesota	United States	56187
71	Baptist Memorial Hospital and Cancer Center-Golden Triangle	Columbus	Mississippi	United States	39705
72	Baptist Cancer Center-Grenada	Grenada	Mississippi	United States	38901
73	Baptist Memorial Hospital and Cancer Center-Union County	New Albany	Mississippi	United States	38652
74	Baptist Memorial Hospital and Cancer Center-Oxford	Oxford	Mississippi	United States	38655
75	Baptist Memorial Hospital and Cancer Center-Desoto	Southhaven	Mississippi	United States	38671
76	Centerpoint Medical Center LLC	Independence	Missouri	United States	64057
77	Research Medical Center	Kansas City	Missouri	United States	64132
78	Mercy Hospital Saint Louis	Saint Louis	Missouri	United States	63141
79	Mercy Hospital Springfield	Springfield	Missouri	United States	65804
80	CoxHealth South Hospital	Springfield	Missouri	United States	65807
81	Billings Clinic Cancer Center	Billings	Montana	United States	59101
82	Bozeman Deaconess Hospital	Bozeman	Montana	United States	59715
83	CHI Health Saint Francis	Grand Island	Nebraska	United States	68803
84	University of New Mexico Cancer Center	Albuquerque	New Mexico	United States	87102
85	Presbyterian Kaseman Hospital	Albuquerque	New Mexico	United States	87110
86	Presbyterian Rust Medical Center/Jorgensen Cancer Center	Rio Rancho	New Mexico	United States	87124
87	Christus Saint Vincent Regional Cancer Center	Santa Fe	New Mexico	United States	87505
88	NYP/Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center	New York	New York	United States	10032
89	Novant Health Oncology Specialists-Kernersville	Kernersville	North Carolina	United States	27284
90	Novant Health Oncology Specialists-Mount Airy	Mount Airy	North Carolina	United States	27030
91	Novant Health Oncology Specialists-Statesville	Statesville	North Carolina	United States	28625
92	Novant Health Oncology Specialists-Davidson County	Thomasville	North Carolina	United States	27360
93	Novant Health Oncology Specialists-Wilkesboro	Wilkesboro	North Carolina	United States	28659
94	Novant Health Forsyth Medical Center	Winston-Salem	North Carolina	United States	27103
95	Novant Health Oncology Specialists	Winston-Salem	North Carolina	United States	27103
96	Sanford Bismarck Medical Center	Bismarck	North Dakota	United States	58501
97	Essentia Health Cancer Center-South University Clinic	Fargo	North Dakota	United States	58103
98	Sanford Broadway Medical Center	Fargo	North Dakota	United States	58122
99	Sanford Roger Maris Cancer Center	Fargo	North Dakota	United States	58122
100	Dayton Physicians LLC-Miami Valley South	Centerville	Ohio	United States	45459
101	Adena Regional Medical Center	Chillicothe	Ohio	United States	45601
102	Dayton Physician LLC-Miami Valley Hospital North	Dayton	Ohio	United States	45415
103	Dayton Physicians LLC-Atrium	Franklin	Ohio	United States	45005
104	Dayton Physicians LLC-Wayne	Greenville	Ohio	United States	45331
105	Greater Dayton Cancer Center	Kettering	Ohio	United States	45409
106	Dayton Physicians LLC-Signal Point	Middletown	Ohio	United States	45042
107	Dayton Physicians LLC-Wilson	Sidney	Ohio	United States	45365
108	Dayton Physicians LLC-Upper Valley	Troy	Ohio	United States	45373
109	Geisinger Medical Center	Danville	Pennsylvania	United States	17822
110	Geisinger Medical Center-Cancer Center Hazleton	Hazleton	Pennsylvania	United States	18201
111	Geisinger Medical Oncology-Lewisburg	Lewisburg	Pennsylvania	United States	17837
112	Lewistown Hospital	Lewistown	Pennsylvania	United States	17044
113	Geisinger Cancer Services-Pottsville	Pottsville	Pennsylvania	United States	17901
114	Community Medical Center	Scranton	Pennsylvania	United States	18510
115	Geisinger Medical Oncology-Selinsgrove	Selinsgrove	Pennsylvania	United States	17870
116	Geisinger Medical Group	State College	Pennsylvania	United States	16801
117	Geisinger Wyoming Valley/Henry Cancer Center	Wilkes-Barre	Pennsylvania	United States	18711
118	Gibbs Cancer Center-Gaffney	Gaffney	South Carolina	United States	29341
119	Greenville Health System Cancer Institute-Butternut	Greenville	South Carolina	United States	29605
120	Greenville Health System Cancer Institute-Faris	Greenville	South Carolina	United States	29605
121	Greenville Memorial Hospital	Greenville	South Carolina	United States	29605
122	Greenville Health System Cancer Institute-Eastside	Greenville	South Carolina	United States	29615
123	Greenville Health System Cancer Institute-Greer	Greer	South Carolina	United States	29650
124	Gibbs Cancer Center-Pelham	Greer	South Carolina	United States	29651
125	Greenville Health System Cancer Institute-Seneca	Seneca	South Carolina	United States	29672
126	Spartanburg Medical Center	Spartanburg	South Carolina	United States	29303
127	Greenville Health System Cancer Institute-Spartanburg	Spartanburg	South Carolina	United States	29307
128	MGC Hematology Oncology-Union	Union	South Carolina	United States	29379
129	Sanford Cancer Center Oncology Clinic	Sioux Falls	South Dakota	United States	57104
130	Sanford USD Medical Center - Sioux Falls	Sioux Falls	South Dakota	United States	57117-5134
131	Baptist Memorial Hospital and Cancer Center-Collierville	Collierville	Tennessee	United States	38017
132	Integrity Oncology PLLC-Collierville	Collierville	Tennessee	United States	38017
133	Baptist Memorial Hospital and Cancer Center-Memphis	Memphis	Tennessee	United States	38120
134	Family Cancer Center-Memphis	Memphis	Tennessee	United States	38120
135	Meharry Medical College	Nashville	Tennessee	United States	37208
136	Logan Regional Hospital	Logan	Utah	United States	84321
137	Intermountain Medical Center	Murray	Utah	United States	84107
138	McKay-Dee Hospital Center	Ogden	Utah	United States	84403
139	Dixie Medical Center Regional Cancer Center	Saint George	Utah	United States	84770
140	MultiCare Auburn Medical Center	Auburn	Washington	United States	98001
141	Swedish Cancer Institute-Edmonds	Edmonds	Washington	United States	98026
142	MultiCare Gig Harbor Medical Park	Gig Harbor	Washington	United States	98335
143	Swedish Cancer Institute-Issaquah	Issaquah	Washington	United States	98029
144	MultiCare Good Samaritan Hospital	Puyallup	Washington	United States	98372
145	Swedish Medical Center-Ballard Campus	Seattle	Washington	United States	98107
146	Swedish Medical Center-First Hill	Seattle	Washington	United States	98122-4307
147	Swedish Medical Center-Cherry Hill	Seattle	Washington	United States	98122-5711
148	MultiCare Tacoma General Hospital	Tacoma	Washington	United States	98405
149	Marshfield Clinic-Chippewa Center	Chippewa Falls	Wisconsin	United States	54729
150	Marshfield Clinic Cancer Center at Sacred Heart	Eau Claire	Wisconsin	United States	54701
151	Marshfield Medical Center-EC Cancer Center	Eau Claire	Wisconsin	United States	54701
152	Marshfield Clinic - Ladysmith Center	Ladysmith	Wisconsin	United States	54848
153	Marshfield Medical Center-Marshfield	Marshfield	Wisconsin	United States	54449
154	Marshfield Clinic-Minocqua Center	Minocqua	Wisconsin	United States	54548
155	Marshfield Medical Center-Rice Lake	Rice Lake	Wisconsin	United States	54868
156	Marshfield Clinic Stevens Point Center	Stevens Point	Wisconsin	United States	54482
157	Marshfield Clinic-Wausau Center	Wausau	Wisconsin	United States	54401
158	Marshfield Clinic - Weston Center	Weston	Wisconsin	United States	54476
159	Marshfield Clinic - Wisconsin Rapids Center	Wisconsin Rapids	Wisconsin	United States	54494
160	Doctors Cancer Center	Manati		Puerto Rico	00674