Five or Ten Year Colonoscopy for 1-2 Non-Advanced Adenomatous Polyps
Summary
This trial examines colorectal cancer incidence in participants with 1 to 2 non-advanced adenomas randomized to surveillance colonoscopy at 10 years compared to participants randomized to surveillance colonoscopy at 5 and 10 years.
Detailed description
Colorectal cancer (CRC) is the fourth most common cancer and the second leading cause of cancer death among men and women in the United States (US). The lifetime risk of colorectal cancer in both men and women in the US is approximately 6%. About 93% of colorectal cancer (CRC) diagnoses are in patients older than 50 years (Siegel 2014). Randomized controlled trials show that screening for CRC significantly decreases CRC incidence and mortality (Schoen 2012, Atkin 2010, Mandel 1999, Mandel 2000). CRC screening has received a Grade A recommendation from the US Preventive Services Task Force. In the U.S., colonoscopy is the most utilized screening modality for CRC. On a population basis, screening rates, which were around 40-50%, have now increased to 65%, and a goal to increase to 80% compliance is being promoted (CDC 2011, CDC 2013, Meester 2015). Adenomatous polyps are the acknowledged precursors of colorectal cancer. Identification and removal of adenomas is the mechanism by which screening is effective in reducing CRC incidence and subsequent mortality. "Advanced" adenomas are adenomas which are greater than or equal to 1 cm, or have a "villous" component (tubulovillous or villous), or have foci of high grade dysplasia. Advanced adenomas are associated with increased long-term risk of cancer, even years after colonoscopy (Click 2018). The prevalence of advanced adenomas at screening colonoscopy is 5-10% (Ferlitsch 2011, Imperiale 2014). Non-advanced adenomas are adenomas greater than 1 cm with neither villous components nor high grade dysplasia. Non-advanced adenomas are much more common than advanced adenomas, present in around 30% of colonoscopy exams (Ferlitsch 2011, Imperiale 2014). After detection of adenomas, patients are advised to return periodically for surveillance colonoscopy. Patients with 1-2 non-advanced adenomas are recommended by guidelines to return in 5 - 10 years for follow-up surveillance colonoscopy (Lieberman 2012). However, there are no guidelines on how to triage individuals to 5 as opposed to 10 years. Furthermore, there is limited evidence supporting the effectiveness of surveillance colonoscopy in reducing CRC incidence. A retrospective study in patients with advanced adenomas demonstrated benefit (Atkin 2017), but the study was not randomized and did not include patients with 1-2 non-advanced adenomas. The only randomized trial of surveillance colonoscopy was reported in the early 1990's, when participants were randomized to 3 vs. 1- and 3- year surveillance (Winawer 1993). No difference in advanced adenoma detection was observed when comparing participants examined at the two screening intervals, and as a result, guidelines were modified with participants advised to return every 3 years after adenomatous polyp detection. The recommended interval for non-advanced adenomas was gradually lengthened to the current standard, but there is no randomized, controlled data to support that interval. Furthermore, observational data of surveillance colonoscopy practice in the U.S. demonstrate that recommended intervals are often not adhered to, and individuals return for repeat testing well ahead of guideline recommendations (Schoen 2010, Lieberman 2014). Furthermore, if anything, retrospective, natural history studies of non-advanced adenomas do not support the association of non-advanced adenoma with a higher risk of subsequent colorectal cancer (Atkin 1992, Spencer 1984, Loberg 2014). For example, in a classic study from the United Kingdom, patients with small rectosigmoid adenomas, even if multiple, did not have an increased risk of CRC compared to the general population, over a 14-year mean follow-up time (Atkin 1992). In a recent observational study from Norway, participants with a low-risk adenoma followed over a median of 7.7 years (maximum 19 years) without subsequent surveillance colonoscopy, had a lower CRC mortality than the general population (Loberg 2014), implying that although the initial colonoscopy may be protective, subsequent follow-up colonoscopy was not required. More recently, several studies have reported that individuals with non-advanced adenomas do not have an increased risk of colorectal cancer compared to those with no adenomas (Click 2018, Lieberman 2019, Lee 2019). Another recent major development affecting screening is that practitioners of colonoscopy are now recommended to monitor and insure their adenoma detection rates are high. Data from Poland (Kaminski 2010) and Kaiser Permanente in California (Corley 2014) have demonstrated that a higher adenoma detection rate (ADR) is associated with a lower long-term risk of interval CRC, or cancer occurring after colonoscopy. Our understanding of these observations is premised on the notion that leaving pre-neoplastic tissue (adenomas) in situ, (such as what occurs with a lower ADR), increases the chance that an adenoma left behind will subsequently transform into cancer. The concern over interval cancers has stimulated quality concerns about the practice of colonoscopy. Guidelines for a recommended ADR at screening colonoscopy are rising, from the initial targets of 15% in women and 25% in men (Lieberman 2012) to 20% in women and 30% in men or 25% overall. ADRs in clinical studies are now commonly over 30% and some practitioners report rates exceeding 50%. However, adenomas that are detected when the ADR is high or as it increases over time are generally small, non-advanced adenomas. Current clinical practice favoring colonoscopy-based screening with increased emphasis on detection of adenomas, most of which will turn out to be small, non-advanced adenomas, will greatly increase demand for utilization of surveillance colonoscopy exams in the coming decades. Yet, the evidence for determining the benefit, optimal timing, and recommended frequency of surveillance colonoscopy is unknown. A randomized, clinical trial to demonstrate the difference in yield between 5- or 10-year surveillance for participants with non-advanced adenoma is needed to guide clinical practice. Only a randomized trial will be authoritative enough to define good clinical practice and directly influence clinical care.
Arms & interventions
- Procedure5-year and 10 Year Surveillance Colonoscopy after Qualifying Colonoscopy
The five- and ten-year colonoscopies, in addition to any unscheduled colonoscopies, will be performed according to currently accepted guidelines for the performance of quality colonoscopy. Participants will be given the standardized colonoscopy preparation instructions per institutional standards.
Outcome measures
Primary
Incidence of colorectal cancer
To examine colorectal cancer incidence in participants with 1 to 2 non-advanced adenomas randomized to surveillance colonoscopy at 10 years compared to participants randomized to surveillance colonoscopy at 5 and 10 years.
Time frame: 10 years
Eligibility criteria
Study locations (472)
Fairbanks Memorial Hospital
Fairbanks, Alaska, 99701
CTCA at Western Regional Medical Center
Goodyear, Arizona, 85338
Kingman Regional Medical Center
Kingman, Arizona, 86401
Cancer Center at Saint Joseph's
Phoenix, Arizona, 85004
University of Arizona Cancer Center - Prevention Research Clinic
Tucson, Arizona, 85719
Mercy Hospital Fort Smith
Fort Smith, Arkansas, 72903
CHI Saint Vincent Cancer Center Hot Springs
Hot Springs, Arkansas, 71913
CARTI Cancer Center
Little Rock, Arkansas, 72205
Kaiser Permanente-Anaheim
Anaheim, California, 92806
Mission Hope Medical Oncology - Arroyo Grande
Arroyo Grande, California, 93420
PCR Oncology
Arroyo Grande, California, 93420
Kaiser Permanente-Baldwin Park
Baldwin Park, California, 91706
Kaiser Permanente-Bellflower
Bellflower, California, 90706
Mercy Cancer Center - Carmichael
Carmichael, California, 95608
Mercy San Juan Medical Center
Carmichael, California, 95608
Epic Care-Dublin
Dublin, California, 94568
Mercy Cancer Center - Elk Grove
Elk Grove, California, 95758
Bay Area Breast Surgeons Inc
Emeryville, California, 94608
Epic Care Partners in Cancer Care
Emeryville, California, 94608
Kaiser Permanente-Fontana
Fontana, California, 92335
Kaiser Permanente South Bay
Harbor City, California, 90710
Kaiser Permanente-Irvine
Irvine, California, 92618
Kaiser Permanente Los Angeles Medical Center
Los Angeles, California, 90027
Kaiser Permanente West Los Angeles
Los Angeles, California, 90034
UCLA / Jonsson Comprehensive Cancer Center
Los Angeles, California, 90095
Contra Costa Regional Medical Center
Martinez, California, 94553-3156
Mercy Cancer Center
Merced, California, 95340
Alta Bates Summit Medical Center - Summit Campus
Oakland, California, 94609
Bay Area Tumor Institute
Oakland, California, 94609
Kaiser Permanente-Ontario
Ontario, California, 91761
Stanford Cancer Institute Palo Alto
Palo Alto, California, 94304
Kaiser Permanente - Panorama City
Panorama City, California, 91402
Kaiser Permanente-Riverside
Riverside, California, 92505
Mercy Cancer Center - Rocklin
Rocklin, California, 95765
Mercy Cancer Center - Sacramento
Sacramento, California, 95816
Kaiser Permanente-San Diego Mission
San Diego, California, 92108
Kaiser Permanente-San Diego Zion
San Diego, California, 92120
Pacific Central Coast Health Center-San Luis Obispo
San Luis Obispo, California, 93401
Kaiser Permanente-San Marcos
San Marcos, California, 92078
Mission Hope Medical Oncology - Santa Maria
Santa Maria, California, 93444
Saint Joseph's Medical Center
Stockton, California, 95204
Kaiser Permanente-Vallejo
Vallejo, California, 94589
Epic Care Cyberknife Center
Walnut Creek, California, 94597
BASS Medical Group - Lennon
Walnut Creek, California, 94598
Woodland Memorial Hospital
Woodland, California, 95695
Kaiser Permanente-Woodland Hills
Woodland Hills, California, 91367
Rocky Mountain Cancer Centers-Aurora
Aurora, Colorado, 80012
Rocky Mountain Regional VA Medical Center
Aurora, Colorado, 80045
UCHealth University of Colorado Hospital
Aurora, Colorado, 80045
Boulder Community Foothills Hospital
Boulder, Colorado, 80303
Rocky Mountain Cancer Centers-Boulder
Boulder, Colorado, 80304
Rocky Mountain Cancer Centers - Centennial
Centennial, Colorado, 80112
Penrose-Saint Francis Healthcare
Colorado Springs, Colorado, 80907
Rocky Mountain Cancer Centers-Penrose
Colorado Springs, Colorado, 80907
Saint Francis Cancer Center
Colorado Springs, Colorado, 80923
Kaiser Permanente-Franklin
Denver, Colorado, 80205
The Women's Imaging Center
Denver, Colorado, 80209
AdventHealth Porter
Denver, Colorado, 80210
Colorado Blood Cancer Institute
Denver, Colorado, 80218
Presbyterian - Saint Lukes Medical Center - Health One
Denver, Colorado, 80218
Rocky Mountain Cancer Centers-Midtown
Denver, Colorado, 80218
Rocky Mountain Cancer Centers-Rose
Denver, Colorado, 80220
CommonSpirit Cancer Center Mercy
Durango, Colorado, 81301
Mercy Medical Center
Durango, Colorado, 81301
Mountain Blue Cancer Care Center - Swedish
Englewood, Colorado, 80113
Rocky Mountain Cancer Centers - Swedish
Englewood, Colorado, 80113
The Melanoma and Skin Cancer Institute
Englewood, Colorado, 80113
Kaiser Permanente-Rock Creek
Lafayette, Colorado, 80026
CommonSpirit Saint Anthony Hospital Cancer Center
Lakewood, Colorado, 80228
Rocky Mountain Cancer Centers-Lakewood
Lakewood, Colorado, 80228
Rocky Mountain Cancer Centers-Littleton
Littleton, Colorado, 80120
AdventHealth Littleton
Littleton, Colorado, 80122
Kaiser Permanente-Lone Tree
Lone Tree, Colorado, 80124
Rocky Mountain Cancer Centers-Sky Ridge
Lone Tree, Colorado, 80124
Longmont United Hospital
Longmont, Colorado, 80501
Rocky Mountain Cancer Centers-Longmont
Longmont, Colorado, 80501
AdventHealth Parker
Parker, Colorado, 80138
Saint Mary Corwin Medical Center
Pueblo, Colorado, 81004
Rocky Mountain Cancer Centers-Thornton
Thornton, Colorado, 80260
Saint Anthony North Hospital
Westminster, Colorado, 80023
Yale-New Haven Hospital Saint Raphael Campus
New Haven, Connecticut, 06511
Yale University
New Haven, Connecticut, 06520
Yale-New Haven Hospital North Haven Medical Center
North Haven, Connecticut, 06473
Veterans Affairs Connecticut Healthcare System-West Haven Campus
West Haven, Connecticut, 06516
Kaiser Permanente-Capitol Hill Medical Center
Washington D.C., District of Columbia, 20002
MedStar Georgetown University Hospital
Washington D.C., District of Columbia, 20007
George Washington University Medical Center
Washington D.C., District of Columbia, 20037
Mount Sinai Comprehensive Cancer Center at Aventura
Aventura, Florida, 33180
Bay Pines VA Healthcare System
Bay Pines, Florida, 33744
Malcom Randall Veterans Administration Medical Center
Gainesville, Florida, 32610
University of Miami Miller School of Medicine-Sylvester Cancer Center
Miami, Florida, 33136
Gastro Health - Galloway
Miami, Florida, 33176
Mount Sinai Medical Center
Miami Beach, Florida, 33140
Piedmont Hospital
Atlanta, Georgia, 30309
Augusta University Medical Center
Augusta, Georgia, 30912
Low Country Cancer Care
Savannah, Georgia, 31404
Memorial Health University Medical Center
Savannah, Georgia, 31404
Hawaii Cancer Care Inc - Waterfront Plaza
Honolulu, Hawaii, 96813
Queen's Medical Center
Honolulu, Hawaii, 96813
Straub Clinic and Hospital
Honolulu, Hawaii, 96813
University of Hawaii Cancer Center
Honolulu, Hawaii, 96813
Kuakini Medical Center
Honolulu, Hawaii, 96817
Queen's Cancer Center - Kuakini
Honolulu, Hawaii, 96817
Kapiolani Medical Center for Women and Children
Honolulu, Hawaii, 96826
Wilcox Memorial Hospital and Kauai Medical Clinic
Lihue, Hawaii, 96766
Pali Momi Medical Center
‘Aiea, Hawaii, 96701
Queen's Cancer Center - Pearlridge
‘Aiea, Hawaii, 96701
Saint Alphonsus Cancer Care Center-Boise
Boise, Idaho, 83706
Saint Alphonsus Cancer Care Center-Caldwell
Caldwell, Idaho, 83605
Kootenai Health - Coeur d'Alene
Coeur d'Alene, Idaho, 83814
Walter Knox Memorial Hospital
Emmett, Idaho, 83617
Idaho Urologic Institute-Meridian
Meridian, Idaho, 83642
Saint Alphonsus Cancer Care Center-Nampa
Nampa, Idaho, 83687
Kootenai Clinic Cancer Services - Post Falls
Post Falls, Idaho, 83854
Kootenai Clinic Cancer Services - Sandpoint
Sandpoint, Idaho, 83864
OSF Saint Anthony's Health Center
Alton, Illinois, 62002
Rush-Copley Medical Center
Aurora, Illinois, 60504
Saint Mary's Hospital
Centralia, Illinois, 62801
Northwestern University
Chicago, Illinois, 60611
John H Stroger Jr Hospital of Cook County
Chicago, Illinois, 60612
Rush MD Anderson Cancer Center
Chicago, Illinois, 60612
Carle at The Riverfront
Danville, Illinois, 61832
Carle Physician Group-Effingham
Effingham, Illinois, 62401
Carle Physician Group-Mattoon/Charleston
Mattoon, Illinois, 61938
Loyola University Medical Center
Maywood, Illinois, 60153
SSM Health Good Samaritan
Mount Vernon, Illinois, 62864
Mercyhealth Cancer Institute - Rockford
Rockford, Illinois, 61114
Carle Cancer Center
Urbana, Illinois, 61801
The Carle Foundation Hospital
Urbana, Illinois, 61801
Rush-Copley Healthcare Center
Yorkville, Illinois, 60560
Midwestern Regional Medical Center
Zion, Illinois, 60099
Northwest Cancer Center - Crown Point
Crown Point, Indiana, 46307
Northwest Oncology LLC
Dyer, Indiana, 46311
Northwest Cancer Center - Hobart
Hobart, Indiana, 46342
Saint Mary Medical Center
Hobart, Indiana, 46342
Saint Catherine Hospital
Indianapolis, Indiana, 46312
The Community Hospital
Munster, Indiana, 46321
Women's Diagnostic Center - Munster
Munster, Indiana, 46321
Reid Health
Richmond, Indiana, 47374
Northwest Cancer Center - Valparaiso
Valparaiso, Indiana, 46383
Mercy Cancer Center-West Lakes
Clive, Iowa, 50325
UI Health Care Mission Cancer and Blood - West Des Moines Clinic
Clive, Iowa, 50325
Alegent Health Mercy Hospital
Council Bluffs, Iowa, 51503
Greater Regional Medical Center
Creston, Iowa, 50801
Mercy Medical Center - Des Moines
Des Moines, Iowa, 50314
UI Health Care Mission Cancer and Blood - Laurel Clinic
Des Moines, Iowa, 50314
Mercy Medical Center-West Lakes
West Des Moines, Iowa, 50266
University of Kansas Clinical Research Center
Fairway, Kansas, 66205
Central Care Cancer Center - Garden City
Garden City, Kansas, 67846
Central Care Cancer Center - Great Bend
Great Bend, Kansas, 67530
University of Kansas Cancer Center
Kansas City, Kansas, 66160
University of Kansas Hospital-Indian Creek Campus
Overland Park, Kansas, 66211
Labette Health
Parsons, Kansas, 67357
Mercy Hospital Pittsburg
Pittsburg, Kansas, 66762
Cotton O'Neil Cancer Center / Stormont Vail Health
Topeka, Kansas, 66606
University of Kansas Hospital-Westwood Cancer Center
Westwood, Kansas, 66205
Robert J Dole VA Medical Center
Wichita, Kansas, 67218
Flaget Memorial Hospital
Bardstown, Kentucky, 40004
Commonwealth Cancer Center-Corbin
Corbin, Kentucky, 40701
Saint Elizabeth Healthcare Edgewood
Edgewood, Kentucky, 41017
Saint Elizabeth Healthcare Fort Thomas
Fort Thomas, Kentucky, 41075
Saint Joseph Hospital
Lexington, Kentucky, 40504
Saint Joseph Radiation Oncology Resource Center
Lexington, Kentucky, 40504
Saint Joseph Hospital East
Lexington, Kentucky, 40509
Saint Joseph London
London, Kentucky, 40741
Jewish Hospital
Louisville, Kentucky, 40202
Saints Mary and Elizabeth Hospital
Louisville, Kentucky, 40215
UofL Health Medical Center Northeast
Louisville, Kentucky, 40245
Saint Joseph Mount Sterling
Mount Sterling, Kentucky, 40353
Mercy Health - Paducah Cancer Center
Paducah, Kentucky, 42003
Jewish Hospital Medical Center South
Shepherdsville, Kentucky, 40165
Louisiana State University Health Science Center
New Orleans, Louisiana, 70112
LSU Health Sciences Center at Shreveport
Shreveport, Louisiana, 71103
MaineHealth Maine Medical Center- Scarborough
Scarborough, Maine, 04074
Kaiser Permanente-Woodlawn Medical Center
Baltimore, Maryland, 21244
Kaiser Permanente-Gaithersburg Medical Center
Gaithersburg, Maryland, 20879
Kaiser Permanente - Kensington Medical Center
Kensington, Maryland, 20895
Kaiser Permanente - Largo Medical Center
Largo, Maryland, 20774
Kaiser Permanente Lutherville - Timonium Medical Center
Lutherville, Maryland, 21093
Massachusetts General Hospital Cancer Center
Boston, Massachusetts, 02114
Boston Veteran's Affairs Medical Center
Jamaica Plain, Massachusetts, 02130
University of Michigan Rogel Cancer Center
Ann Arbor, Michigan, 48109
Bronson Battle Creek
Battle Creek, Michigan, 49017
Corewell Health Grand Rapids Hospitals - Butterworth Hospital
Grand Rapids, Michigan, 49503
Corewell Health Grand Rapids Hospitals - Helen DeVos Children's Hospital
Grand Rapids, Michigan, 49503
Trinity Health Grand Rapids Hospital
Grand Rapids, Michigan, 49503
Bronson Methodist Hospital
Kalamazoo, Michigan, 49007
West Michigan Cancer Center
Kalamazoo, Michigan, 49007
Beacon Kalamazoo Cancer Center
Kalamazoo, Michigan, 49009
Beacon Kalamazoo
Kalamazoo, Michigan, 49048
Trinity Health Muskegon Hospital
Muskegon, Michigan, 49444
Corewell Health Lakeland Hospitals - Niles Hospital
Niles, Michigan, 49120
Cancer and Hematology Centers of Western Michigan - Norton Shores
Norton Shores, Michigan, 49444
Corewell Health Reed City Hospital
Reed City, Michigan, 49677
Corewell Health Lakeland Hospitals - Marie Yeager Cancer Center
Saint Joseph, Michigan, 49085
Corewell Health Lakeland Hospitals - Saint Joseph Hospital
Saint Joseph, Michigan, 49085
Munson Medical Center
Traverse City, Michigan, 49684
University of Michigan Health - West
Wyoming, Michigan, 49519
Riverwood Healthcare Center
Aitkin, Minnesota, 56431
Essentia Health - Baxter Clinic
Baxter, Minnesota, 56425
Sanford Joe Lueken Cancer Center
Bemidji, Minnesota, 56601
Essentia Health Saint Joseph's Medical Center
Brainerd, Minnesota, 56401
Fairview Ridges Hospital
Burnsville, Minnesota, 55337
Minnesota Oncology - Burnsville
Burnsville, Minnesota, 55337
Cambridge Medical Center
Cambridge, Minnesota, 55008
Minnesota Oncology Hematology PA-Chaska
Chaska, Minnesota, 55318
Mercy Hospital
Coon Rapids, Minnesota, 55433
Minnesota Oncology - Coon Rapids
Coon Rapids, Minnesota, 55433
Essentia Health - Saint Joseph's Crosslake Clinic
Crosslake, Minnesota, 56442
Essentia Health - Deer River Clinic
Deer River, Minnesota, 56636
Essentia Health Saint Mary's - Detroit Lakes Clinic
Detroit Lakes, Minnesota, 56501
Essentia Health Cancer Center
Duluth, Minnesota, 55805
Essentia Health Saint Mary's Medical Center
Duluth, Minnesota, 55805
Miller-Dwan Hospital
Duluth, Minnesota, 55805
Fairview Southdale Hospital
Edina, Minnesota, 55435
Minnesota Oncology - Edina
Edina, Minnesota, 55435
Essentia Health - Ely Clinic
Ely, Minnesota, 55731
Lake Region Healthcare Corporation-Cancer Care
Fergus Falls, Minnesota, 56537
Essentia Health - Fosston
Fosston, Minnesota, 56542
Unity Hospital
Fridley, Minnesota, 55432
Essentia Health Hibbing Clinic
Hibbing, Minnesota, 55746
Essentia Health - International Falls Clinic
International Falls, Minnesota, 56649
Fairview Clinics and Surgery Center Maple Grove
Maple Grove, Minnesota, 55369
Minnesota Oncology - Maple Grove
Maple Grove, Minnesota, 55369
Minnesota Oncology Hematology PA-Maplewood
Maplewood, Minnesota, 55109
Saint John's Hospital - Healtheast
Maplewood, Minnesota, 55109
Abbott-Northwestern Hospital
Minneapolis, Minnesota, 55407
Hennepin County Medical Center
Minneapolis, Minnesota, 55415
Minneapolis VA Medical Center
Minneapolis, Minnesota, 55417
Health Partners Inc
Minneapolis, Minnesota, 55454
Monticello Cancer Center
Monticello, Minnesota, 55362
Essentia Health - Moose Lake Clinic
Moose Lake, Minnesota, 55767
New Ulm Medical Center
New Ulm, Minnesota, 56073
Essentia Health - Park Rapids
Park Rapids, Minnesota, 56470
Essentia Health - Saint Joseph's Pequot Lakes Clinic
Pequot Lakes, Minnesota, 56472
Essentia Health - Saint Joseph's Pine River Clinic
Pine River, Minnesota, 56474
Fairview Northland Medical Center
Princeton, Minnesota, 55371
North Memorial Medical Health Center
Robbinsdale, Minnesota, 55422
Mayo Clinic in Rochester
Rochester, Minnesota, 55905
Park Nicollet Clinic - Saint Louis Park
Saint Louis Park, Minnesota, 55416
Regions Hospital
Saint Paul, Minnesota, 55101
United Hospital
Saint Paul, Minnesota, 55102
Essentia Health Sandstone
Sandstone, Minnesota, 55072
Saint Francis Regional Medical Center
Shakopee, Minnesota, 55379
Essentia Health - Saint Joseph's Staples Clinic
Staples, Minnesota, 56479
Lakeview Hospital
Stillwater, Minnesota, 55082
Sanford Thief River Falls Medical Center
Thief River Falls, Minnesota, 56701
Essentia Health Virginia Clinic
Virginia, Minnesota, 55792
Ridgeview Medical Center
Waconia, Minnesota, 55387
Rice Memorial Hospital
Willmar, Minnesota, 56201
Minnesota Oncology Hematology PA-Woodbury
Woodbury, Minnesota, 55125
Sanford Cancer Center Worthington
Worthington, Minnesota, 56187
Fairview Lakes Medical Center
Wyoming, Minnesota, 55092
Mercy Oncology and Hematology - Clayton-Clarkson
Ballwin, Missouri, 63011
Central Care Cancer Center - Bolivar
Bolivar, Missouri, 65613
Cox Cancer Center Branson
Branson, Missouri, 65616
Mercy Cancer Center - Cape Girardeau
Cape Girardeau, Missouri, 63703
Freeman Health System
Joplin, Missouri, 64804
Mercy Hospital Joplin
Joplin, Missouri, 64804
Kansas City Veterans Affairs Medical Center
Kansas City, Missouri, 64128
Lake Regional Hospital
Osage Beach, Missouri, 65065
Mercy Clinic-Rolla-Cancer and Hematology
Rolla, Missouri, 65401
Phelps Health Delbert Day Cancer Institute
Rolla, Missouri, 65401
Heartland Regional Medical Center
Saint Joseph, Missouri, 64506
Mercy Hospital Springfield
Springfield, Missouri, 65804
CoxHealth South Hospital
Springfield, Missouri, 65807
Mercy Infusion Center - Chippewa
St Louis, Missouri, 63109
Mercy Hospital South
St Louis, Missouri, 63128
Mercy Hospital Saint Louis
St Louis, Missouri, 63141
Mercy Hospital Washington
Washington, Missouri, 63090
Community Hospital of Anaconda
Anaconda, Montana, 59711
Billings Clinic Cancer Center
Billings, Montana, 59101
Bozeman Health Deaconess Hospital
Bozeman, Montana, 59715
Benefis Sletten Cancer Institute
Great Falls, Montana, 59405
Great Falls Clinic
Great Falls, Montana, 59405
Hi-Line Sletten Cancer Center
Havre, Montana, 59501
Benefis Helena Specialty Center
Helena, Montana, 59601
Logan Health Medical Center
Kalispell, Montana, 59901
Community Medical Center
Missoula, Montana, 59804
CHI Health Saint Francis
Grand Island, Nebraska, 68803
Nebraska Cancer Specialists/Oncology Hematology West PC
Grand Island, Nebraska, 68803
CHI Health Good Samaritan
Kearney, Nebraska, 68847
Saint Elizabeth Regional Medical Center
Lincoln, Nebraska, 68510
Alegent Health Immanuel Medical Center
Omaha, Nebraska, 68122
Alegent Health Bergan Mercy Medical Center
Omaha, Nebraska, 68124
Alegent Health Lakeside Hospital
Omaha, Nebraska, 68130
Creighton University Medical Center
Omaha, Nebraska, 68131
Midlands Community Hospital
Papillion, Nebraska, 68046
Carson Tahoe Regional Medical Center
Carson City, Nevada, 89703
Cancer and Blood Specialists-Henderson
Henderson, Nevada, 89052
Comprehensive Cancer Centers of Nevada - Henderson
Henderson, Nevada, 89052
Comprehensive Cancer Centers of Nevada-Horizon Ridge
Henderson, Nevada, 89052
Comprehensive Cancer Centers of Nevada-Southeast Henderson
Henderson, Nevada, 89074
Las Vegas Urology - Green Valley
Henderson, Nevada, 89074
Las Vegas Urology - Pebble
Henderson, Nevada, 89074
Oncology Las Vegas - Henderson
Henderson, Nevada, 89074
Urology Specialists of Nevada - Green Valley
Henderson, Nevada, 89074
Las Vegas Urology - Pecos
Las Vegas, Nevada, 89074
OptumCare Cancer Care at Charleston
Las Vegas, Nevada, 89102
University Medical Center of Southern Nevada
Las Vegas, Nevada, 89102
Hope Cancer Care of Nevada
Las Vegas, Nevada, 89103
Radiation Oncology Centers of Nevada Central
Las Vegas, Nevada, 89106
Urology Specialists of Nevada - Central
Las Vegas, Nevada, 89106
Women's Cancer Center of Nevada
Las Vegas, Nevada, 89106
Sunrise Hospital and Medical Center
Las Vegas, Nevada, 89109
Las Vegas Prostate Cancer Center
Las Vegas, Nevada, 89113
Las Vegas Urology - Sunset
Las Vegas, Nevada, 89113
Urology Specialists of Nevada - Southwest
Las Vegas, Nevada, 89113
Radiation Oncology Centers of Nevada Southeast
Las Vegas, Nevada, 89119
Ann M Wierman MD LTD
Las Vegas, Nevada, 89128
Comprehensive Cancer Centers of Nevada - Northwest
Las Vegas, Nevada, 89128
Las Vegas Urology - Cathedral Rock
Las Vegas, Nevada, 89128
Las Vegas Urology - Smoke Ranch
Las Vegas, Nevada, 89128
Oncology Las Vegas - Tenaya
Las Vegas, Nevada, 89128
OptumCare Cancer Care at MountainView
Las Vegas, Nevada, 89128
Urology Specialists of Nevada - Northwest
Las Vegas, Nevada, 89128
Alliance for Childhood Diseases/Cure 4 the Kids Foundation
Las Vegas, Nevada, 89135
Comprehensive Cancer Centers of Nevada - Town Center
Las Vegas, Nevada, 89144
Comprehensive Cancer Centers of Nevada-Summerlin
Las Vegas, Nevada, 89144
Summerlin Hospital Medical Center
Las Vegas, Nevada, 89144
Comprehensive Cancer Centers of Nevada
Las Vegas, Nevada, 89148
Comprehensive Cancer Centers of Nevada - Central Valley
Las Vegas, Nevada, 89169
University Cancer Center
Las Vegas, Nevada, 89169
OptumCare Cancer Care at Fort Apache
Las Vegas, Nevada, 89183
Hope Cancer Care of Nevada-Pahrump
Pahrump, Nevada, 89048
Renown Regional Medical Center
Reno, Nevada, 89502
Saint Mary's Regional Medical Center
Reno, Nevada, 89503
Radiation Oncology Associates
Reno, Nevada, 89509
Morristown Medical Center
Morristown, New Jersey, 07960
Lovelace Medical Center-Saint Joseph Square
Albuquerque, New Mexico, 87102
University of New Mexico Cancer Center
Albuquerque, New Mexico, 87106
Laura and Isaac Perlmutter Cancer Center at NYU Langone
New York, New York, 10016
NYP/Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center
New York, New York, 10032
Southeastern Medical Oncology Center-Clinton
Clinton, North Carolina, 28328
Southeastern Medical Oncology Center-Goldsboro
Goldsboro, North Carolina, 27534
Southeastern Medical Oncology Center-Jacksonville
Jacksonville, North Carolina, 28546
Sanford Bismarck Medical Center
Bismarck, North Dakota, 58501
Essentia Health Cancer Center-South University Clinic
Fargo, North Dakota, 58103
Sanford South University Medical Center
Fargo, North Dakota, 58103
Southpointe-Sanford Medical Center Fargo
Fargo, North Dakota, 58103
Sanford Medical Center Fargo
Fargo, North Dakota, 58104
Sanford Broadway Medical Center
Fargo, North Dakota, 58122
Sanford Roger Maris Cancer Center
Fargo, North Dakota, 58122
Altru Cancer Center
Grand Forks, North Dakota, 58201
Essentia Health - Jamestown Clinic
Jamestown, North Dakota, 58401
UHHS-Chagrin Highlands Medical Center
Beachwood, Ohio, 44122
Indu and Raj Soin Medical Center
Beavercreek, Ohio, 45431
Saint Elizabeth Boardman Hospital
Boardman, Ohio, 44512
Dayton Physicians LLC-Miami Valley South
Centerville, Ohio, 45459
Miami Valley Hospital South
Centerville, Ohio, 45459
University of Cincinnati Cancer Center-UC Medical Center
Cincinnati, Ohio, 45219
Good Samaritan Hospital - Cincinnati
Cincinnati, Ohio, 45220
Oncology Hematology Care Inc-Kenwood
Cincinnati, Ohio, 45236
Bethesda North Hospital
Cincinnati, Ohio, 45242
TriHealth Cancer Institute-Westside
Cincinnati, Ohio, 45247
TriHealth Cancer Institute-Anderson
Cincinnati, Ohio, 45255
Case Western Reserve University
Cleveland, Ohio, 44106
Louis Stokes Cleveland VA Medical Center
Cleveland, Ohio, 44106
Ohio State University Comprehensive Cancer Center
Columbus, Ohio, 43210
Miami Valley Hospital
Dayton, Ohio, 45409
Premier Blood and Cancer Center
Dayton, Ohio, 45409
Dayton Physician LLC - Englewood
Dayton, Ohio, 45415
Miami Valley Hospital North
Dayton, Ohio, 45415
Armes Family Cancer Center
Findlay, Ohio, 45840
Blanchard Valley Hospital
Findlay, Ohio, 45840
Orion Cancer Care
Findlay, Ohio, 45840
Atrium Medical Center-Middletown Regional Hospital
Franklin, Ohio, 45005-1066
Dayton Physicians LLC-Atrium
Franklin, Ohio, 45005
Dayton Physicians LLC-Wayne
Greenville, Ohio, 45331
Miami Valley Cancer Care and Infusion
Greenville, Ohio, 45331
Wayne Hospital
Greenville, Ohio, 45331
Greater Dayton Cancer Center
Kettering, Ohio, 45409
Kettering Medical Center
Kettering, Ohio, 45429
Dayton Physicians LLC - Troy
Troy, Ohio, 45373
Upper Valley Medical Center
Troy, Ohio, 45373
Saint Joseph Warren Hospital
Warren, Ohio, 44484
University of Cincinnati Cancer Center-West Chester
West Chester, Ohio, 45069
UHHS-Westlake Medical Center
Westlake, Ohio, 44145
Saint Elizabeth Youngstown Hospital
Youngstown, Ohio, 44501
Veterans Administration Medical Center - Oklahoma City
Oklahoma City, Oklahoma, 73104
Mercy Hospital Oklahoma City
Oklahoma City, Oklahoma, 73120
Saint Alphonsus Cancer Care Center-Baker City
Baker City, Oregon, 97814
Saint Alphonsus Cancer Care Center-Ontario
Ontario, Oregon, 97914
Oregon Health and Science University
Portland, Oregon, 97239
Portland VA Medical Center
Portland, Oregon, 97239
Saint Luke's Cancer Center - Allentown
Allentown, Pennsylvania, 18104
Saint Luke's University Hospital-Bethlehem Campus
Bethlehem, Pennsylvania, 18015
Geisinger Medical Center
Danville, Pennsylvania, 17822
Saint Luke's Hospital-Anderson Campus
Easton, Pennsylvania, 18045
Geisinger Medical Center-Cancer Center Hazleton
Hazleton, Pennsylvania, 18201
Geisinger Medical Oncology-Lewisburg
Lewisburg, Pennsylvania, 17837
UPMC-Presbyterian Hospital
Pittsburgh, Pennsylvania, 15213
Geisinger Cancer Services-Pottsville
Pottsville, Pennsylvania, 17901
Saint Luke's Hospital - Upper Bucks Campus
Quakertown, Pennsylvania, 18951
Community Medical Center
Scranton, Pennsylvania, 18510
Saint Luke's Hospital - Monroe Campus
Stroudsburg, Pennsylvania, 18360
Geisinger Wyoming Valley/Henry Cancer Center
Wilkes-Barre, Pennsylvania, 18711
Providence Veterans Administration Hospital
Providence, Rhode Island, 02908
Beaufort Memorial Hospital
Beaufort, South Carolina, 29902
Ralph H Johnson VA Medical Center
Charleston, South Carolina, 29401
Medical University of South Carolina
Charleston, South Carolina, 29425
Gibbs Cancer Center-Gaffney
Gaffney, South Carolina, 29341
Prisma Health Greenville Memorial Hospital
Greenville, South Carolina, 29605
Gibbs Cancer Center-Pelham
Greer, South Carolina, 29651
North Grove Medical Park
Spartanburg, South Carolina, 29303
Spartanburg Medical Center
Spartanburg, South Carolina, 29303
Spartanburg Medical Center - Mary Black Campus
Spartanburg, South Carolina, 29307
SMC Center for Hematology Oncology Union
Union, South Carolina, 29379
Sanford Cancer Center Oncology Clinic
Sioux Falls, South Dakota, 57104
Sanford USD Medical Center - Sioux Falls
Sioux Falls, South Dakota, 57117-5134
Baptist Memorial Hospital and Cancer Center-Memphis
Memphis, Tennessee, 38120
Saint Joseph Regional Cancer Center
Bryan, Texas, 77802
UT Southwestern/Simmons Cancer Center-Dallas
Dallas, Texas, 75390
Baylor College of Medicine/Dan L Duncan Comprehensive Cancer Center
Houston, Texas, 77030
Audie L Murphy VA Hospital
San Antonio, Texas, 78229
George E Wahlen Department of Veterans Affairs Medical Center
Salt Lake City, Utah, 84148
Kaiser Permanente-Burke Medical Center
Burke, Virginia, 22015
Sovah Health Martinsville
Martinsville, Virginia, 24112
Kaiser Permanente Tysons Corner Medical Center
McLean, Virginia, 22102
VCU Massey Cancer Center at Stony Point
Richmond, Virginia, 23235
VCU Massey Comprehensive Cancer Center
Richmond, Virginia, 23298
Carilion Roanoke Memorial Hospital
Roanoke, Virginia, 24033
Kaiser Permanente-Caton Hill Medical Center
Woodbridge, Virginia, 22192
Highline Medical Center-Main Campus
Burien, Washington, 98166
Saint Elizabeth Hospital
Enumclaw, Washington, 98022
Saint Francis Hospital
Federal Way, Washington, 98003
Saint Clare Hospital
Lakewood, Washington, 98499
Jefferson Healthcare
Port Townsend, Washington, 98368
Valley Medical Center
Renton, Washington, 98055
Saint Joseph Medical Center Hematology and Oncology - Silverdale
Silverdale, Washington, 98383
Franciscan Research Center-Northwest Medical Plaza
Tacoma, Washington, 98405
North Star Lodge Cancer Center at Yakima Valley Memorial Hospital
Yakima, Washington, 98902
United Hospital Center
Bridgeport, West Virginia, 26330
WVUH-Berkely Medical Center
Martinsburg, West Virginia, 25401
West Virginia University Healthcare
Morgantown, West Virginia, 26506
Camden Clark Medical Center
Parkersburg, West Virginia, 26101
Princeton Community Hospital
Princeton, West Virginia, 24740
Wheeling Hospital/Schiffler Cancer Center
Wheeling, West Virginia, 26003
Ascension Saint Elizabeth Hospital
Appleton, Wisconsin, 54915
Duluth Clinic Ashland
Ashland, Wisconsin, 54806
Northwest Wisconsin Cancer Center
Ashland, Wisconsin, 54806
Ascension Southeast Wisconsin Hospital - Elmbrook Campus
Brookfield, Wisconsin, 53045
Ascension Calumet Hospital
Chilton, Wisconsin, 53014
Marshfield Medical Center-EC Cancer Center
Eau Claire, Wisconsin, 54701
Ascension Saint Francis - Reiman Cancer Center
Franklin, Wisconsin, 53132
Ascension Southeast Wisconsin Hospital - Franklin
Franklin, Wisconsin, 53132
Saint Vincent Hospital Cancer Center Green Bay
Green Bay, Wisconsin, 54301
Saint Vincent Hospital Cancer Center at Saint Mary's
Green Bay, Wisconsin, 54303
Essentia Health-Hayward Clinic
Hayward, Wisconsin, 54843
Tamarack Health Hayward Medical Center
Hayward, Wisconsin, 54843
Mercyhealth Hospital and Cancer Center - Janesville
Janesville, Wisconsin, 53548
William S Middleton VA Medical Center
Madison, Wisconsin, 53705
Marshfield Medical Center-Marshfield
Marshfield, Wisconsin, 54449
Ascension Columbia Saint Mary's Hospital Ozaukee
Mequon, Wisconsin, 53097
Ascension Southeast Wisconsin Hospital - Saint Joseph Campus
Milwaukee, Wisconsin, 53210
Ascension Columbia Saint Mary's Hospital - Milwaukee
Milwaukee, Wisconsin, 53211
Ascension Saint Francis Hospital
Milwaukee, Wisconsin, 53215
Zablocki Veterans Administration Medical Center
Milwaukee, Wisconsin, 53295
Marshfield Medical Center - Minocqua
Minocqua, Wisconsin, 54548
Cancer Center of Western Wisconsin
New Richmond, Wisconsin, 54017
Ascension Mercy Hospital
Oshkosh, Wisconsin, 54904
Ascension All Saints Hospital
Racine, Wisconsin, 53405
Marshfield Medical Center-Rice Lake
Rice Lake, Wisconsin, 54868
Essentia Health-Spooner Clinic
Spooner, Wisconsin, 54801
Marshfield Medical Center-River Region at Stevens Point
Stevens Point, Wisconsin, 54482
Essentia Health Saint Mary's Hospital - Superior
Superior, Wisconsin, 54880
Marshfield Clinic-Wausau Center
Wausau, Wisconsin, 54401
Ascension Medical Group Southeast Wisconsin - Mayfair Road
Wauwatosa, Wisconsin, 53226
Marshfield Medical Center - Weston
Weston, Wisconsin, 54476
Memorial Hospital of Laramie County
Cheyenne, Wyoming, 82001
Billings Clinic-Cody
Cody, Wyoming, 82414
Welch Cancer Center
Sheridan, Wyoming, 82801