Radiation Therapy With or Without Chemotherapy in Treating Patients With High-Risk Malignant Salivary Gland Tumors That Have Been Removed By Surgery

Sponsor

Radiation Therapy Oncology Group (Other)

Overall Status

Active, not recruiting

CT.gov ID

NCT01220583

Collaborator

National Cancer Institute (NCI) (NIH), NRG Oncology (Other)

252

Enrollment

268

Locations

Arms

213

Duration (Months)

0.9

Patients Per Site

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

RATIONALE: Radiation therapy uses high-energy x-rays to kill tumor cells. Drugs used in chemotherapy, such as cisplatin, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. It is not yet known whether radiation therapy is more effective when given together with chemotherapy or alone after surgery in treating salivary gland tumors.

PURPOSE: This randomized phase II/III trial is studying radiation therapy with or without chemotherapy to see how well it works in treating patients with high-risk malignant salivary gland tumors that have been removed by surgery.

Condition or Disease	Intervention/Treatment	Phase
Head and Neck Cancer	Drug: cisplatin Radiation: 3-dimensional conformal radiation therapy Radiation: intensity-modulated radiation therapy	Phase 2

Detailed Description

OBJECTIVES:

Primary

Phase II

Determine the feasibility of conducting a cooperative group prospective clinical trial in patients with resected malignant salivary gland tumors.
Acquire preliminary efficacy data comparing postoperative radiotherapy alone to concurrent chemotherapy and radiation using weekly cisplatin.

Phase III

Compare overall survival rates among patients receiving cisplatin and radiation to those receiving radiation alone.

Secondary

Phase II/III

Compare the acute toxicities of these 2 adjuvant treatments.
Compare late treatment-related adverse events in patients receiving postoperative radiation to those receiving concurrent chemoradiation.
Compare progression-free survival rates among patients receiving cisplatin and radiation to those receiving radiation alone in both the cohort of patients with pathologically high-risk disease (high-grade adenocarcinoma, high-grade mucoepidermoid carcinoma, salivary duct carcinoma), and the patient cohort with pathologically intermediate-risk disease (all other eligible diagnoses).
Investigate quality of life and patient-reported outcomes in patients enrolled in the study.
Identify the histopathology and tumor marker expression from patients enrolled on this trial and assemble a tissue bank for future correlative studies.
Establish a NRG Oncology baseline database for salivary gland malignancies to serve as a resource for future exploration of innovative and/or targeted approaches for this disease.

OUTLINE: This is a multicenter study. Patients are stratified according to histology (high-grade mucoepidermoid carcinoma vs salivary duct carcinoma vs high-grade adenocarcinoma) and nodal status (N0 vs N1-3). Patients are randomized to 1 of 2 treatment arms.

Arm I: Patients undergo 3-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiotherapy (IMRT) 5 days a week for 6-6.5 weeks. Patients also receive cisplatin IV over 60 minutes on days 1, 8, 15, 22, 29, 36, and 43 during radiotherapy.
Arm II: Patients undergo 3D-CRT or IMRT as in Arm I. Tissue and blood samples may be collected for translational research studies. Patients may complete quality-of-life assessments periodically.

After completion of study treatment, patients are followed up at 3, 6, 9, 12, and 24 months, every 6 months for 2 years, and then annually thereafter.

Study Design

Study Type:

Interventional

Actual Enrollment :

252 participants

Allocation:

Randomized

Intervention Model:

Parallel Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

A Randomized Phase II/Phase III Study of Adjuvant Concurrent Radiation and Chemotherapy Versus Radiation Alone in Resected High-Risk Malignant Salivary Gland Tumors

Study Start Date :

Jan 1, 2011

Anticipated Primary Completion Date :

Oct 1, 2023

Anticipated Study Completion Date :

Oct 1, 2028

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Arm I Patients undergo 3-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiotherapy (IMRT) 5 days a week for 6-6.5 weeks. Patients also receive cisplatin IV over 60 minutes on days 1, 8, 15, 22, 29, 36, and 43 during radiotherapy.	Drug: cisplatin Given IV Radiation: 3-dimensional conformal radiation therapy Undergo radiotherapy Radiation: intensity-modulated radiation therapy Undergo radiotherapy
Experimental: Arm II Patients undergo 3D-CRT or IMRT as in arm I.	Radiation: 3-dimensional conformal radiation therapy Undergo radiotherapy Radiation: intensity-modulated radiation therapy Undergo radiotherapy

Arm

Intervention/Treatment

Experimental: Arm I

Patients undergo 3-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiotherapy (IMRT) 5 days a week for 6-6.5 weeks. Patients also receive cisplatin IV over 60 minutes on days 1, 8, 15, 22, 29, 36, and 43 during radiotherapy.

Drug: cisplatin

Given IV

Radiation: 3-dimensional conformal radiation therapy

Undergo radiotherapy

Radiation: intensity-modulated radiation therapy

Undergo radiotherapy

Experimental: Arm II

Patients undergo 3D-CRT or IMRT as in arm I.

Radiation: 3-dimensional conformal radiation therapy

Undergo radiotherapy

Radiation: intensity-modulated radiation therapy

Undergo radiotherapy

Outcome Measures

Primary Outcome Measures

Progression-free survival (PFS), defined by the events of local-regional progression or recurrence, distant metastasis, or death from any cause, primarily at 2 years [From randomization to 2 years.]

Secondary Outcome Measures

Overall survival (OS) rate at 2 years [From randomization to 2 years.]
PFS rate at 5 years [From randomization to 5 years.]
OS rate at 5 years [From randomization to 5 years.]
Treatment-related toxicity, defined as any grade 3-4 adverse events (CTCAE v. 4) deemed to be definitely, probably, or possibly related to protocol treatment [From start of treatment to last follow-up.]
Treatment-related mortality, defined as any death during or within 30 days of discontinuation of protocol treatment [From start of treatment to 30 days after the end of treatment.]
Chemotherapy delivery as measured by percentage of protocol prescription given [From start of treatment to end of treatment.]
Radiation delivery as measured by elapsed treatment days [From start of treatment to end of treatment.]
Determine whether quality of life, fatigue and xerostomia differ as a function of treatment assignment at 3, 12, and 24 months after completing radiotherapy. [From randomization to 2 years.]

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years and Older

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

DISEASE CHARACTERISTICS:

Pathologically proven diagnosis of a malignant major salivary gland tumor or malignant minor salivary gland tumor of the head and neck of the following histologic subtypes:
Intermediate-grade adenocarcinoma or intermediate-grade mucoepidermoid carcinoma
High-grade acinic cell carcinoma or high-grade (>30% solid component) adenoid cystic carcinoma
Surgical resection with curative intent within 8 weeks prior to registration
All patients must have a Medical Oncology evaluation within 4 weeks prior to registration
Pathologic stage T3-4 or N1-3 or T1-2, N0 with a close (≤ 1mm) or microscopically positive surgical margin; patients must be free of distant metastases based upon the following minimum diagnostic workup:
History/physical examination within 8 weeks prior to registration
Radiologic confirmation of the absence of hematogenous metastasis within 12 weeks prior to registration; at a minimum, contrast CT imaging of the chest is required (PET/CT is acceptable)
No patients with residual macroscopic disease after surgery
No prior systemic chemotherapy or radiation therapy for salivary gland malignancy

PATIENT CHARACTERISTICS:

Zubrod performance status 0-1
Absolute neutrophil count (ANC) ≥ 1,800 cells/mm^3
Platelets ≥ 100,000 cells/mm^3
Hemoglobin ≥ 8.0 g/dL (the use of transfusion or other intervention to achieve hemoglobin ≥ 8.0 g/dL is acceptable)
Serum creatinine < 2.0 mg/dL
Total bilirubin < 2 x the institutional upper limit of normal (ULN)
Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) < 3 x the institutional ULN
Negative serum pregnancy test within 2 weeks prior to registration for women of childbearing potential
Women of childbearing potential and male participants who are sexually active must practice adequate contraception during treatment and for 6 weeks following treatment
Not pregnant or nursing
Patients must be deemed able to comply with the treatment plan and follow-up schedule
Patients must provide study specific informed consent prior to study entry, including consent for mandatory tissue submission for central review
No prior invasive malignancy (except non-melanomatous skin cancer) unless disease free for a minimum of 3 years (for example, carcinoma in situ of the breast, oral cavity, or cervix are all permissible)
No severe, active co-morbidity, defined as follows:
Unstable angina and/or congestive heart failure requiring hospitalization within the last 6 months
Transmural myocardial infarction within the last 6 months
Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration
Chronic Obstructive Pulmonary Disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy at the time of registration
Hepatic insufficiency resulting in clinical jaundice and/or coagulation defects (coagulation parameters are not required for entry into this protocol)
Acquired immune deficiency syndrome (AIDS) based upon current Centers for Disease Control (CDC) definition (HIV testing is not required for entry into this protocol)
Protocol-specific requirements may also exclude immunocompromised patients
Pre-existing ≥ grade 2 neuropathy
No significant pre-existing hearing loss, as defined by the patient or treating physician

PRIOR CONCURRENT THERAPY:

See Disease Characteristics
No prior systemic chemotherapy or radiation therapy for salivary gland malignancy (prior chemotherapy for a different cancer is allowable)
No prior radiotherapy to the region of the study cancer that would result in overlap of radiation therapy fields
No prior organ transplant
No concurrent hematopoietic growth factors (e.g., G-CSF or pegfilgrastim) during radiotherapy
No concurrent erythropoiesis-stimulating agents

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	University of Alabama at Birmingham Cancer Center	Birmingham	Alabama	United States	35233
2	The Kirklin Clinic at Acton Road	Birmingham	Alabama	United States	35243
3	Arizona Breast Cancer Specialists-Gilbert	Gilbert	Arizona	United States	85297
4	Arizona Center for Cancer Care-Peoria	Peoria	Arizona	United States	85381
5	Cancer Center at Saint Joseph's	Phoenix	Arizona	United States	85004
6	Arizona Breast Cancer Specialists-Phoenix	Phoenix	Arizona	United States	85027
7	Arizona Oncology-Deer Valley Center	Phoenix	Arizona	United States	85027
8	Arizona Breast Cancer Specialists	Scottsdale	Arizona	United States	85251
9	Arizona Breast Cancer Specialists-Scottsdale	Scottsdale	Arizona	United States	85258
10	Arizona Oncology Services Foundation	Scottsdale	Arizona	United States	85260
11	Arizona Center for Cancer Care-Surprise	Surprise	Arizona	United States	85374
12	University of Arizona Cancer Center-Orange Grove Campus	Tucson	Arizona	United States	85704
13	Banner University Medical Center - Tucson	Tucson	Arizona	United States	85719
14	University of Arizona Cancer Center-North Campus	Tucson	Arizona	United States	85719
15	Sutter Cancer Centers Radiation Oncology Services-Auburn	Auburn	California	United States	95603
16	AIS Cancer Center at San Joaquin Community Hospital	Bakersfield	California	United States	93301
17	Mills-Peninsula Medical Center	Burlingame	California	United States	94010
18	Sutter Cancer Centers Radiation Oncology Services-Cameron Park	Cameron Park	California	United States	95682
19	Mercy San Juan Medical Center	Carmichael	California	United States	95608
20	City of Hope Comprehensive Cancer Center	Duarte	California	United States	91010
21	UC San Diego Moores Cancer Center	La Jolla	California	United States	92093
22	Los Angeles County-USC Medical Center	Los Angeles	California	United States	90033
23	USC / Norris Comprehensive Cancer Center	Los Angeles	California	United States	90033
24	Fremont - Rideout Cancer Center	Marysville	California	United States	95901
25	Memorial Medical Center	Modesto	California	United States	95355
26	Hoag Memorial Hospital	Newport Beach	California	United States	92663
27	Saint Joseph Hospital - Orange	Orange	California	United States	92868
28	Stanford Cancer Institute Palo Alto	Palo Alto	California	United States	94304
29	Sutter Cancer Centers Radiation Oncology Services-Roseville	Roseville	California	United States	95661
30	Sutter Medical Center Sacramento	Sacramento	California	United States	95816
31	University of California Davis Comprehensive Cancer Center	Sacramento	California	United States	95817
32	UCSF Medical Center-Mount Zion	San Francisco	California	United States	94115
33	UCSF Medical Center-Mission Bay	San Francisco	California	United States	94158
34	Sutter Cancer Centers Radiation Oncology Services-Vacaville	Vacaville	California	United States	95687
35	Rocky Mountain Cancer Centers-Aurora	Aurora	Colorado	United States	80012
36	University of Colorado Hospital	Aurora	Colorado	United States	80045
37	Boulder Community Hospital	Boulder	Colorado	United States	80301
38	Penrose-Saint Francis Healthcare	Colorado Springs	Colorado	United States	80907
39	Porter Adventist Hospital	Denver	Colorado	United States	80210
40	Swedish Medical Center	Englewood	Colorado	United States	80113
41	Rocky Mountain Cancer Centers-Littleton	Littleton	Colorado	United States	80120
42	Longmont United Hospital	Longmont	Colorado	United States	80501
43	McKee Medical Center	Loveland	Colorado	United States	80539
44	North Suburban Medical Center	Thornton	Colorado	United States	80229
45	Rocky Mountain Cancer Centers-Thornton	Thornton	Colorado	United States	80260
46	William Backus Hospital	Norwich	Connecticut	United States	06360
47	Helen F Graham Cancer Center	Newark	Delaware	United States	19713
48	Christiana Care Health System-Christiana Hospital	Newark	Delaware	United States	19718
49	Beebe Health Campus	Rehoboth Beach	Delaware	United States	19971
50	UM Sylvester Comprehensive Cancer Center at Coral Gables	Coral Gables	Florida	United States	33146
51	UM Sylvester Comprehensive Cancer Center at Deerfield Beach	Deerfield Beach	Florida	United States	33442
52	University of Florida Health Science Center - Gainesville	Gainesville	Florida	United States	32610
53	Baptist MD Anderson Cancer Center	Jacksonville	Florida	United States	32207
54	University of Florida Health Science Center - Jacksonville	Jacksonville	Florida	United States	32209
55	University of Miami Miller School of Medicine-Sylvester Cancer Center	Miami	Florida	United States	33136
56	Miami Cancer Institute	Miami	Florida	United States	33176
57	Orlando Health Cancer Institute	Orlando	Florida	United States	32806
58	Moffitt Cancer Center	Tampa	Florida	United States	33612
59	Emory Proton Therapy Center	Atlanta	Georgia	United States	30308
60	Emory University Hospital Midtown	Atlanta	Georgia	United States	30308
61	Emory University Hospital/Winship Cancer Institute	Atlanta	Georgia	United States	30322
62	Memorial Health University Medical Center	Savannah	Georgia	United States	31404
63	Saint Alphonsus Cancer Care Center-Boise	Boise	Idaho	United States	83706
64	Kootenai Clinic Cancer Services - Post Falls	Post Falls	Idaho	United States	83854
65	Northwestern University	Chicago	Illinois	United States	60611
66	John H Stroger Jr Hospital of Cook County	Chicago	Illinois	United States	60612
67	Loyola University Medical Center	Maywood	Illinois	United States	60153
68	Saint John's Hospital	Springfield	Illinois	United States	62702
69	IU Health North Hospital	Carmel	Indiana	United States	46032
70	Goshen Center for Cancer Care	Goshen	Indiana	United States	46526
71	Indiana University/Melvin and Bren Simon Cancer Center	Indianapolis	Indiana	United States	46202
72	Sidney and Lois Eskenazi Hospital	Indianapolis	Indiana	United States	46202
73	Memorial Hospital of South Bend	South Bend	Indiana	United States	46601
74	McFarland Clinic PC - Ames	Ames	Iowa	United States	50010
75	Iowa Methodist Medical Center	Des Moines	Iowa	United States	50309
76	Mercy Medical Center - Des Moines	Des Moines	Iowa	United States	50314
77	University of Iowa/Holden Comprehensive Cancer Center	Iowa City	Iowa	United States	52242
78	Siouxland Regional Cancer Center	Sioux City	Iowa	United States	51101
79	University of Kansas Cancer Center	Kansas City	Kansas	United States	66160
80	University of Kentucky/Markey Cancer Center	Lexington	Kentucky	United States	40536
81	The James Graham Brown Cancer Center at University of Louisville	Louisville	Kentucky	United States	40202
82	Mary Bird Perkins Cancer Center	Baton Rouge	Louisiana	United States	70809
83	University Medical Center New Orleans	New Orleans	Louisiana	United States	70112
84	Touro Infirmary	New Orleans	Louisiana	United States	70115
85	Ochsner Medical Center Jefferson	New Orleans	Louisiana	United States	70121
86	Greater Baltimore Medical Center	Baltimore	Maryland	United States	21204
87	Johns Hopkins University/Sidney Kimmel Cancer Center	Baltimore	Maryland	United States	21287
88	Boston Medical Center	Boston	Massachusetts	United States	02118
89	Bixby Medical Center	Adrian	Michigan	United States	49221
90	Saint Joseph Mercy Hospital	Ann Arbor	Michigan	United States	48106
91	University of Michigan Comprehensive Cancer Center	Ann Arbor	Michigan	United States	48109
92	Henry Ford Cancer Institute-Downriver	Brownstown	Michigan	United States	48183
93	Henry Ford Macomb Hospital-Clinton Township	Clinton Township	Michigan	United States	48038
94	Wayne State University/Karmanos Cancer Institute	Detroit	Michigan	United States	48201
95	Henry Ford Hospital	Detroit	Michigan	United States	48202
96	Ascension Saint John Hospital	Detroit	Michigan	United States	48236
97	Weisberg Cancer Treatment Center	Farmington Hills	Michigan	United States	48334
98	Genesys Hurley Cancer Institute	Flint	Michigan	United States	48503
99	West Michigan Cancer Center	Kalamazoo	Michigan	United States	49007
100	Saint Mary Mercy Hospital	Livonia	Michigan	United States	48154
101	Saint Joseph Mercy Oakland	Pontiac	Michigan	United States	48341
102	Lake Huron Medical Center	Port Huron	Michigan	United States	48060
103	Ascension Saint Mary's Hospital	Saginaw	Michigan	United States	48601
104	Saint John Macomb-Oakland Hospital	Warren	Michigan	United States	48093
105	Henry Ford West Bloomfield Hospital	West Bloomfield	Michigan	United States	48322
106	Mayo Clinic in Rochester	Rochester	Minnesota	United States	55905
107	University of Mississippi Medical Center	Jackson	Mississippi	United States	39216
108	University of Missouri - Ellis Fischel	Columbia	Missouri	United States	65212
109	Siteman Cancer Center at West County Hospital	Creve Coeur	Missouri	United States	63141
110	Freeman Health System	Joplin	Missouri	United States	64804
111	Delbert Day Cancer Institute at PCRMC	Rolla	Missouri	United States	65401
112	SSM Health Saint Louis University Hospital	Saint Louis	Missouri	United States	63104
113	Washington University School of Medicine	Saint Louis	Missouri	United States	63110
114	Siteman Cancer Center-South County	Saint Louis	Missouri	United States	63129
115	Siteman Cancer Center at Saint Peters Hospital	Saint Peters	Missouri	United States	63376
116	Mercy Hospital Springfield	Springfield	Missouri	United States	65804
117	Billings Clinic Cancer Center	Billings	Montana	United States	59101
118	Bozeman Deaconess Hospital	Bozeman	Montana	United States	59715
119	Kalispell Regional Medical Center	Kalispell	Montana	United States	59901
120	Nebraska Methodist Hospital	Omaha	Nebraska	United States	68114
121	Alegent Health Bergan Mercy Medical Center	Omaha	Nebraska	United States	68124
122	Comprehensive Cancer Centers of Nevada - Henderson	Henderson	Nevada	United States	89052
123	Radiation Oncology Centers of Nevada Central	Las Vegas	Nevada	United States	89106
124	Comprehensive Cancer Centers of Nevada - Northwest	Las Vegas	Nevada	United States	89128
125	Comprehensive Cancer Centers of Nevada-Summerlin	Las Vegas	Nevada	United States	89144
126	Comprehensive Cancer Centers of Nevada	Las Vegas	Nevada	United States	89148
127	Comprehensive Cancer Centers of Nevada - Central Valley	Las Vegas	Nevada	United States	89169
128	Dartmouth Hitchcock Medical Center	Lebanon	New Hampshire	United States	03756
129	Memorial Sloan Kettering Basking Ridge	Basking Ridge	New Jersey	United States	07920
130	Memorial Sloan Kettering Monmouth	Middletown	New Jersey	United States	07748
131	Memorial Sloan Kettering Bergen	Montvale	New Jersey	United States	07645
132	Virtua Memorial	Mount Holly	New Jersey	United States	08060
133	Rutgers New Jersey Medical School	Newark	New Jersey	United States	07101
134	Sparta Cancer Treatment Center	Sparta	New Jersey	United States	07871
135	Virtua Voorhees	Voorhees	New Jersey	United States	08043
136	University of New Mexico Cancer Center	Albuquerque	New Mexico	United States	87102
137	Northwell Health Imbert Cancer Center	Bay Shore	New York	United States	11706
138	Maimonides Medical Center	Brooklyn	New York	United States	11219
139	Memorial Sloan Kettering Commack	Commack	New York	United States	11725
140	Memorial Sloan Kettering Westchester	Harrison	New York	United States	10604
141	Northwell Health/Center for Advanced Medicine	Lake Success	New York	United States	11042
142	Long Island Jewish Medical Center	New Hyde Park	New York	United States	11040
143	Mount Sinai Union Square	New York	New York	United States	10003
144	Mount Sinai Chelsea	New York	New York	United States	10011
145	Laura and Isaac Perlmutter Cancer Center at NYU Langone	New York	New York	United States	10016
146	Lenox Hill Hospital	New York	New York	United States	10021
147	Mount Sinai Hospital	New York	New York	United States	10029
148	Memorial Sloan Kettering Cancer Center	New York	New York	United States	10065
149	Highland Hospital	Rochester	New York	United States	14620
150	University of Rochester	Rochester	New York	United States	14642
151	Memorial Sloan Kettering Sleepy Hollow	Sleepy Hollow	New York	United States	10591
152	State University of New York Upstate Medical University	Syracuse	New York	United States	13210
153	Memorial Sloan Kettering Nassau	Uniondale	New York	United States	11553
154	UNC Lineberger Comprehensive Cancer Center	Chapel Hill	North Carolina	United States	27599
155	Duke University Medical Center	Durham	North Carolina	United States	27710
156	Summa Health System - Akron Campus	Akron	Ohio	United States	44304
157	Summa Health System - Barberton Campus	Barberton	Ohio	United States	44203
158	University of Cincinnati Cancer Center-UC Medical Center	Cincinnati	Ohio	United States	45219
159	Case Western Reserve University	Cleveland	Ohio	United States	44106
160	Cleveland Clinic Foundation	Cleveland	Ohio	United States	44195
161	Ohio State University Comprehensive Cancer Center	Columbus	Ohio	United States	43210
162	Mercy Cancer Center-Elyria	Elyria	Ohio	United States	44035
163	Summa Health Medina Medical Center	Medina	Ohio	United States	44256
164	UH Seidman Cancer Center at Lake Health Mentor Campus	Mentor	Ohio	United States	44060
165	UH Seidman Cancer Center at Southwest General Hospital	Middleburg Heights	Ohio	United States	44130
166	University Hospitals Parma Medical Center	Parma	Ohio	United States	44129
167	UH Seidman Cancer Center at Salem Regional Medical Center	Salem	Ohio	United States	44460
168	UH Seidman Cancer Center at Firelands Regional Medical Center	Sandusky	Ohio	United States	44870
169	ProMedica Flower Hospital	Sylvania	Ohio	United States	43560
170	University of Toledo	Toledo	Ohio	United States	43614
171	Mercy Health - Saint Anne Hospital	Toledo	Ohio	United States	43623
172	University of Cincinnati Cancer Center-West Chester	West Chester	Ohio	United States	45069
173	Cancer Treatment Center	Wooster	Ohio	United States	44691
174	University of Oklahoma Health Sciences Center	Oklahoma City	Oklahoma	United States	73104
175	Mercy Hospital Oklahoma City	Oklahoma City	Oklahoma	United States	73120
176	Clackamas Radiation Oncology Center	Clackamas	Oregon	United States	97015
177	Providence Portland Medical Center	Portland	Oregon	United States	97213
178	Providence Saint Vincent Medical Center	Portland	Oregon	United States	97225
179	Oregon Health and Science University	Portland	Oregon	United States	97239
180	Lehigh Valley Hospital-Cedar Crest	Allentown	Pennsylvania	United States	18103
181	Bryn Mawr Hospital	Bryn Mawr	Pennsylvania	United States	19010
182	Geisinger Medical Center	Danville	Pennsylvania	United States	17822
183	UPMC Cancer Centers - Arnold Palmer Pavilion	Greensburg	Pennsylvania	United States	15601
184	UPMC Pinnacle Cancer Center/Community Osteopathic Campus	Harrisburg	Pennsylvania	United States	17109
185	Penn State Milton S Hershey Medical Center	Hershey	Pennsylvania	United States	17033-0850
186	Geisinger Medical Oncology-Lewisburg	Lewisburg	Pennsylvania	United States	17837
187	Lewistown Hospital	Lewistown	Pennsylvania	United States	17044
188	UPMC-Coraopolis/Heritage Valley Radiation Oncology	Moon	Pennsylvania	United States	15108
189	UPMC Jameson	New Castle	Pennsylvania	United States	16105
190	Paoli Memorial Hospital	Paoli	Pennsylvania	United States	19301
191	Thomas Jefferson University Hospital	Philadelphia	Pennsylvania	United States	19107
192	Fox Chase Cancer Center	Philadelphia	Pennsylvania	United States	19111
193	Temple University Hospital	Philadelphia	Pennsylvania	United States	19140
194	UPMC-Saint Margaret	Pittsburgh	Pennsylvania	United States	15215
195	UPMC-Shadyside Hospital	Pittsburgh	Pennsylvania	United States	15232
196	UPMC Jefferson Regional Radiation Oncology	Pittsburgh	Pennsylvania	United States	15236
197	UPMC-Passavant Hospital	Pittsburgh	Pennsylvania	United States	15237
198	UPMC-Saint Clair Hospital Cancer Center	Pittsburgh	Pennsylvania	United States	15243
199	Geisinger Wyoming Valley/Henry Cancer Center	Wilkes-Barre	Pennsylvania	United States	18711
200	Lankenau Medical Center	Wynnewood	Pennsylvania	United States	19096
201	Prisma Health Cancer Institute - Spartanburg	Boiling Springs	South Carolina	United States	29316
202	Medical University of South Carolina	Charleston	South Carolina	United States	29425
203	Prisma Health Cancer Institute - Faris	Greenville	South Carolina	United States	29605
204	Prisma Health Cancer Institute - Eastside	Greenville	South Carolina	United States	29615
205	Prisma Health Cancer Institute - Greer	Greer	South Carolina	United States	29650
206	Prisma Health Cancer Institute - Seneca	Seneca	South Carolina	United States	29672
207	Rapid City Regional Hospital	Rapid City	South Dakota	United States	57701
208	University of Tennessee - Knoxville	Knoxville	Tennessee	United States	37920
209	Vanderbilt University/Ingram Cancer Center	Nashville	Tennessee	United States	37232
210	MD Anderson in The Woodlands	Conroe	Texas	United States	77384
211	UT Southwestern/Simmons Cancer Center-Dallas	Dallas	Texas	United States	75390
212	M D Anderson Cancer Center	Houston	Texas	United States	77030
213	MD Anderson West Houston	Houston	Texas	United States	77079
214	MD Anderson League City	League City	Texas	United States	77573
215	MD Anderson in Sugar Land	Sugar Land	Texas	United States	77478
216	American Fork Hospital / Huntsman Intermountain Cancer Center	American Fork	Utah	United States	84003
217	Sandra L Maxwell Cancer Center	Cedar City	Utah	United States	84720
218	Logan Regional Hospital	Logan	Utah	United States	84321
219	Intermountain Medical Center	Murray	Utah	United States	84107
220	Utah Valley Regional Medical Center	Provo	Utah	United States	84604
221	Dixie Medical Center Regional Cancer Center	Saint George	Utah	United States	84770
222	Utah Cancer Specialists-Salt Lake City	Salt Lake City	Utah	United States	84106
223	Norris Cotton Cancer Center-North	Saint Johnsbury	Vermont	United States	05819
224	Inova Schar Cancer Institute	Fairfax	Virginia	United States	22031
225	Inova Fairfax Hospital	Falls Church	Virginia	United States	22042
226	Sentara Cancer Institute at Sentara CarePlex Hospital	Hampton	Virginia	United States	23666
227	Sentara Norfolk General Hospital	Norfolk	Virginia	United States	23507
228	Sentara Virginia Beach General Hospital	Virginia Beach	Virginia	United States	23454
229	Saint Francis Hospital	Federal Way	Washington	United States	98003
230	Seattle Cancer Care Alliance at Northwest Hospital	Seattle	Washington	United States	98133
231	University of Washington Medical Center - Montlake	Seattle	Washington	United States	98195
232	PeaceHealth Southwest Medical Center	Vancouver	Washington	United States	98664
233	Compass Oncology Vancouver	Vancouver	Washington	United States	98684
234	West Virginia University Healthcare	Morgantown	West Virginia	United States	26506
235	Wheeling Hospital/Schiffler Cancer Center	Wheeling	West Virginia	United States	26003
236	Aurora Cancer Care-Southern Lakes VLCC	Burlington	Wisconsin	United States	53105
237	Aurora Health Center-Fond du Lac	Fond Du Lac	Wisconsin	United States	54937
238	Aurora Health Care Germantown Health Center	Germantown	Wisconsin	United States	53022
239	Aurora Cancer Care-Grafton	Grafton	Wisconsin	United States	53024
240	Green Bay Oncology at Saint Vincent Hospital	Green Bay	Wisconsin	United States	54301-3526
241	Saint Vincent Hospital Cancer Center Green Bay	Green Bay	Wisconsin	United States	54301
242	Saint Vincent Hospital Cancer Center at Saint Mary's	Green Bay	Wisconsin	United States	54303
243	Aurora BayCare Medical Center	Green Bay	Wisconsin	United States	54311
244	Aurora Cancer Care-Kenosha South	Kenosha	Wisconsin	United States	53142
245	University of Wisconsin Hospital and Clinics	Madison	Wisconsin	United States	53792
246	Aurora Bay Area Medical Group-Marinette	Marinette	Wisconsin	United States	54143
247	Bay Area Medical Center	Marinette	Wisconsin	United States	54143
248	Aurora Cancer Care-Milwaukee	Milwaukee	Wisconsin	United States	53209
249	Aurora Saint Luke's Medical Center	Milwaukee	Wisconsin	United States	53215
250	Medical College of Wisconsin	Milwaukee	Wisconsin	United States	53226
251	Vince Lombardi Cancer Clinic - Oshkosh	Oshkosh	Wisconsin	United States	54904
252	Aurora Cancer Care-Racine	Racine	Wisconsin	United States	53406
253	Vince Lombardi Cancer Clinic-Sheboygan	Sheboygan	Wisconsin	United States	53081
254	Saint Vincent Hospital Cancer Center at Sturgeon Bay	Sturgeon Bay	Wisconsin	United States	54235-1495
255	Aurora Medical Center in Summit	Summit	Wisconsin	United States	53066
256	Vince Lombardi Cancer Clinic-Two Rivers	Two Rivers	Wisconsin	United States	54241
257	Aurora Cancer Care-Milwaukee West	Wauwatosa	Wisconsin	United States	53226
258	Aurora West Allis Medical Center	West Allis	Wisconsin	United States	53227
259	Aspirus Cancer Care - Wisconsin Rapids	Wisconsin Rapids	Wisconsin	United States	54494
260	Cross Cancer Institute	Edmonton	Alberta	Canada	T6G 1Z2
261	London Regional Cancer Program	London	Ontario	Canada	N6A 4L6
262	Health Sciences North	Sudbury	Ontario	Canada	P3E 5J1
263	University Health Network-Princess Margaret Hospital	Toronto	Ontario	Canada	M5G 2M9
264	CHUM - Hopital Notre-Dame	Montreal	Quebec	Canada	H2L 4M1
265	McGill University Department of Oncology	Montreal	Quebec	Canada	H2W 1S6
266	CHUM - Centre Hospitalier de l'Universite de Montreal	Montreal	Quebec	Canada	H2X 3E4
267	The Research Institute of the McGill University Health Centre (MUHC)	Montreal	Quebec	Canada	H3H 2R9
268	King Faisal Specialist Hospital and Research Centre	Riyadh		Saudi Arabia	11211