S1300: Pemetrexed Disodium With or Without Crizotinib in Treating Patients With Stage IV Non-Small Cell Lung Cancer That Has Progressed After Crizotinib

Phase 2

Terminated

Conditions: Stage IV Non-small Cell Lung Cancer
Large Cell Lung Cancer
Recurrent Non-small Cell Lung Cancer
Adenocarcinoma of the Lung

Interventions: Drug: pemetrexed disodium
Drug: crizotinib
Other: laboratory biomarker analysis
Other: pharmacological study

Registration Number: NCT02134912

Lead Sponsor: SWOG Cancer Research Network

Brief Summary: This randomized phase II trial studies how well pemetrexed disodium with or without crizotinib works in treating patients with stage IV non-small cell lung cancer that has progressed after crizotinib. Drugs used in chemotherapy, such as pemetrexed disodium, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Crizotinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. It is not yet known whether giving pemetrexed disodium is more effective with or without crizotinib in treating patients with non-small cell lung cancer that has progressed after crizotinib.

Detailed Description: PRIMARY OBJECTIVES:

I. To evaluate the efficacy of the combination of crizotinib and pemetrexed (pemetrexed disodium) compared to pemetrexed monotherapy as measured by progression-free survival (PFS) in anaplastic lymphoma kinase (ALK)+ non-squamous non-small cell lung cancer (NSCLC) patients who achieved clinical benefit with crizotinib monotherapy and subsequently progressed systemically.

SECONDARY OBJECTIVES:

I. To compare the response rate (confirmed and unconfirmed, complete and partial responses) in patients randomized to receive pemetrexed monotherapy to historical data.

II. To assess overall survival in both arms. III. To evaluate the patterns of failure (central nervous system \[CNS\], extra-CNS) of the combination of crizotinib and pemetrexed and of pemetrexed monotherapy in ALK+ non-squamous NSCLC after progression on crizotinib.

IV. To evaluate the frequency and severity of toxicities resulting from the administration of crizotinib and pemetrexed compared to pemetrexed monotherapy.

V. To evaluate PFS and the response rate in patients treated with crizotinib following progression on the pemetrexed monotherapy arm.

TERTIARY OBJECTIVES:

I. To compare progression-free survival (PFS) and response rates (RR) between ALK dominant and ALK non-dominant patients in the entire study population and within each treatment arm.

II. To evaluate if the magnitude of difference in these outcomes between ALK dominant and ALK non-dominant patients varies by treatment arm.

III. To assess blood biomarkers of sensitivity and resistance to crizotinib and pemetrexed in an exploratory manner. The blood biomarkers include cell free circulating deoxyribonucleic acid (DNA), micro ribonucleic acid (microRNA) before treatment, during treatment (after 2 cycles) and at treatment progression.

IV. To assess pharmacogenomic factors in peripheral blood that might affect the drug level and treatment outcomes in an exploratory manner.

V. To assess proteomic/immunologic parameters that might affect the treatment outcomes in an exploratory manner.

VI. To evaluate the frequency of individual mechanisms of resistance (copy number gain \[CNG\], mutation, alternate oncogene).

VII. To identify alternative driver mechanisms in ALK fluorescence in situ hybridization positive (FISH+) otherwise unknown.

OUTLINE: Patients are randomized to 1 of 2 treatment arms.

ARM I: Patients receive crizotinib orally (PO) twice daily (BID) on days 1-21 and pemetrexed disodium intravenously (IV) over 10 minutes on day 1.

ARM II: Patients receive pemetrexed disodium IV over 10 minutes on day 1. Upon disease progression or symptomatic deterioration, patients may crossover to Arm I.

In both arms, courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up for 3 years.

Recruitment & Eligibility

Status: TERMINATED

Sex: All

Target Recruitment: 1

Inclusion Criteria

Patients must have histologically or cytologically proven primary non-squamous non-small cell lung cancer (adenocarcinoma, large cell carcinoma, adenocarcinoma in situ, mixed histology with < 50% squamous or unspecified); patients with tumors having squamous cell components >= 50% are not eligible; disease must be stage IV
Patients must have documented ALK positivity at the time of initial crizotinib monotherapy using the Vysis Break-Apart FISH assay (or other Food and Drug Administration [FDA]-approved diagnostic test); samples are deemed to be FISH-positive if greater than or equal to 15% of scored tumor cells had split ALK 5' and 3' probe signals or had isolated 3' signal; FISH status must be documented on the Onstudy Form and a copy of the pathology report from the Vysis Break-Apart FISH assay (or other FDA-approved diagnostic test) must be submitted
Prior to registration, patients must have achieved clinical benefit with crizotinib monotherapy and subsequently have systemically progressed; clinical benefit is defined as having stable disease on crizotinib monotherapy for at least 90 days or achieving a confirmed partial or complete response; systemic progression is defined as progressive disease based on Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, excluding progression based on brain/CNS metastases alone
Patients must have received crizotinib monotherapy at 250 mg BID on a continuous dosing schedule for at least 90 days; patients must be planning to start treatment at least three days, but no more than 30 days after discontinuing crizotinib monotherapy; patients who were not able to tolerate 250 mg BID of crizotinib are not eligible for this study
Patients must be pemetrexed-naïve; patients may have received any number of prior chemotherapy or molecularly targeted agents; if crizotinib was used in the 1st line setting then chemotherapy naive patients are also eligible; if patient received crizotinib in combination with chemotherapy, prior chemotherapy must have been discontinued at least 14 days prior to registration and all adverse events must have resolved to =< grade 1
Patients must have measurable disease per RECIST documented by computed tomography (CT) or magnetic resonance imaging (MRI); the CT from a combined positron emission tomography (PET)/CT may be used to document only non-measurable disease unless it is of diagnostic quality; measurable disease must be assessed within 28 days prior to registration; pleural effusions, ascites and laboratory parameters are not acceptable as the only evidence of disease; non-measurable disease must be assessed within 42 days prior to registration; all disease must be assessed and documented on the Baseline Tumor Assessment Form RECIST 1.1
Patients must have a CT or MRI scan of the brain to evaluate for CNS disease within 42 days prior to registration; patient must not have brain metastases unless: (1) metastases have been treated and have remained controlled for at least 14 days following treatment or was not treated, but is asymptomatic, AND (2) patient has no residual neurological dysfunction off corticosteroids or anti-convulsants for at least 14 days
Patients may have received palliative radiotherapy to non-target lesions within 14 days prior to registration provided all radiotherapy related toxicities have resolved to =< grade 1 prior to registration; patients must not have received any major surgery within 28 days prior to registration
Patients must not have had any prior exposure to heat shock protein (HSP)90 inhibitors (such as IPI-504 or ganetespib) or non-crizotinib ALK inhibitors (such as AP26113 or LDK378)
Patients must be offered participation in the translational medicine studies; additionally if patient has biopsy accessible disease they must be offered participation in the translational medicine studies
Absolute neutrophil count (ANC) >= 1,500/ul
Platelet count >= 100,000/ul
Hemoglobin >= 9 g/dL
Serum bilirubin =< 2 X institutional upper limit of normal (IULN)
Serum glutamic oxaloacetic transaminase (SGOT) (aspartate aminotransferase [AST]) or serum glutamate pyruvate transaminase (SGPT) (alanine aminotransferase [ALT]) =< 2.5 x IULN
Estimated (calculated) or measured glomerular filtration rate >= 45 mL/min (or 45 mL/min/1.73 m^2); creatinine (mg/dl) used in calculation (Cockroft-Gault) must be obtained within 28 days prior to registration
Male patients must have free and total testosterone level obtained within 28 days prior to registration
Pre-study history and physical must be obtained with 28 days prior to registration
Patients must have Zubrod performance status 0-2 within 28 days prior to registration
Patients must be able to swallow capsules
Patients must have corrected QT (QTC) interval =< 480 msec on electrocardiogram (EKG) at baseline; patient with congenital long QT syndrome are not eligible
No other prior malignancy is allowed except for the following: adequately treated basal cell or squamous cell skin cancer, in situ cervical cancer, adequately treated stage I or II cancer from which the patient is currently in complete remission, or any other cancer from which the patient has been disease free for five years
Patients must not be pregnant or nursing; women/men of reproductive potential must have agreed to use an effective contraceptive method; a woman is considered to be of "reproductive potential" if she has had menses at any time in the preceding 12 consecutive months; in addition to routine contraceptive methods, "effective contraception" also includes heterosexual celibacy and surgery intended to prevent pregnancy (or with a side-effect of pregnancy prevention) defined as a hysterectomy, bilateral oophorectomy or bilateral tubal ligation; however, if at any point a previously celibate patient chooses to become heterosexually active during the time period for use of contraceptive measures outlined in the protocol, he/she is responsible for beginning contraceptive measures
REGULATORY CRITERIA: Patients or their legally authorized representative 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
REGULATORY CRITERIA: 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
CROSSOVER (STEP 2) REGISTRATION: Patients must have progressed systemically on Arm 2 of this study (pemetrexed monotherapy)
CROSSOVER (STEP 2) REGISTRATION: Patients must be registered to crossover (Step 2) within 30 days of discontinuing treatment on Arm 2 of this study
CROSSOVER (STEP 2) REGISTRATION: ANC >= 1,500/ul
CROSSOVER (STEP 2) REGISTRATION: Platelet count >= 100,000/ul
CROSSOVER (STEP 2) REGISTRATION: Serum bilirubin =< 2 X IULN
CROSSOVER (STEP 2) REGISTRATION: SGOT (AST) or SGPT (ALT) =< 2.5 x IULN
CROSSOVER (STEP 2) REGISTRATION: estimated (calculated) or measured glomerular filtration rate >= 45 mL/min (or 45 mL/min/1.73 m^2) within 28 days prior to registration; creatinine (mg/dl) used in calculation (Cockroft-Gault) must be obtained within 28 days prior to registration
CROSSOVER (STEP 2) REGISTRATION: male patients must have free and total testosterone level obtained within 28 days prior to Crossover (Step 2) Registration
CROSSOVER (STEP 2) REGISTRATION: patients must have Zubrod performance status 0-2 within 28 days prior to Crossover (Step 2) Registration

Exclusion Criteria

Not provided

Study & Design

Study Type: INTERVENTIONAL

Study Design: CROSSOVER

Arm && Interventions

Group	Intervention	Description
Arm II (pemetrexed disodium)	pemetrexed disodium	ARM II: Patients receive pemetrexed disodium IV over 10 minutes on day 1. Upon disease progression or symptomatic deterioration, patients may crossover to Arm I.
Arm I (crizotinib, pemetrexed disodium)	pharmacological study	Patients receive crizotinib PO BID on days 1-21 and pemetrexed disodium IV over 10 minutes on day 1.
Arm I (crizotinib, pemetrexed disodium)	pemetrexed disodium	Patients receive crizotinib PO BID on days 1-21 and pemetrexed disodium IV over 10 minutes on day 1.
Arm I (crizotinib, pemetrexed disodium)	laboratory biomarker analysis	Patients receive crizotinib PO BID on days 1-21 and pemetrexed disodium IV over 10 minutes on day 1.
Arm II (pemetrexed disodium)	laboratory biomarker analysis	ARM II: Patients receive pemetrexed disodium IV over 10 minutes on day 1. Upon disease progression or symptomatic deterioration, patients may crossover to Arm I.
Arm II (pemetrexed disodium)	pharmacological study	ARM II: Patients receive pemetrexed disodium IV over 10 minutes on day 1. Upon disease progression or symptomatic deterioration, patients may crossover to Arm I.
Arm I (crizotinib, pemetrexed disodium)	crizotinib	Patients receive crizotinib PO BID on days 1-21 and pemetrexed disodium IV over 10 minutes on day 1.

Primary Outcome Measures

Name	Time	Method
PFS Between Patients Randomized to Receive Pemetrexed Disodium Monotherapy Versus Crizotinib and Pemetrexed Disodium Combination Therapy	From date of registration to date of first documentation of progression or symptomatic deterioration, or death due to any cause, assessed up to 3 years	A stratified log-rank test at the 0.10 level will be used to test the primary hypothesis comparing the two treatment arms.

Secondary Outcome Measures

Name	Time	Method
Incidence of Adverse Events of Crizotinib in Combination With Pemetrexed Disodium, Graded According to the National Cancer Institute Common Terminology Criteria for Adverse Events Version 4.0	Up to 3 years	Comparisons of toxicities rates will be done using a Fisher's exact or chi-squared test of independence, when appropriate using 10% as the significance threshold. Within each treatment arm, any toxicity with at least 5% prevalence has at least a 95% chance of being observed.
Response Rate (Confirmed and Unconfirmed) With Pemetrexed Disodium Monotherapy	Up to 3 years	Comparisons of response rates will be done using a chi-square test of independence using 10% as the significance threshold. Within each treatment arm, response rates can be estimated to within 13% (with 95% confidence).
Patterns of Failure	Up to 3 years	Defined as CNS-only, extra-CNS, and both CNS and extra-CNS progression between the treatment arms. Evaluated within each treatment arm using cumulative incidence curves.
Response Rates (Confirmed and Unconfirmed) of Crizotinib With Pemetrexed Disodium	Up to 3 years	Comparisons of response rates will be done using a chi-square test of independence using 10% as the significance threshold. Within each treatment arm, response rates can be estimated to within 13% (with 95% confidence).
Overall Survival	Up to 3 years	Differences in OS by treatment arm will be evaluated using a 1-sided log-rank test with significant level of 10%.

Trial Locations

Locations (166): Sparrow Hospital
🇺🇸
Lansing, Michigan, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸
Boise, Idaho, United States
Kootenai Cancer Center
🇺🇸
Post Falls, Idaho, United States
Flaget Memorial Hospital
🇺🇸
Bardstown, Kentucky, United States
Saint John Macomb-Oakland Hospital
🇺🇸
Warren, Michigan, United States
University of Mississippi Medical Center
🇺🇸
Jackson, Mississippi, United States
CoxHealth South Hospital
🇺🇸
Springfield, Missouri, United States
Benefis Healthcare- Sletten Cancer Institute
🇺🇸
Great Falls, Montana, United States
Saint Patrick Hospital - Community Hospital
🇺🇸
Missoula, Montana, United States
Nebraska Cancer Research Center
🇺🇸
Lincoln, Nebraska, United States
Saint Elizabeth Regional Medical Center
🇺🇸
Lincoln, Nebraska, United States
Grant Medical Center
🇺🇸
Columbus, Ohio, United States
Riverside Methodist Hospital
🇺🇸
Columbus, Ohio, United States
Kettering Medical Center
🇺🇸
Kettering, Ohio, United States
Upper Valley Medical Center
🇺🇸
Troy, Ohio, United States
Licking Memorial Hospital
🇺🇸
Newark, Ohio, United States
Genesys Hurley Cancer Institute
🇺🇸
Flint, Michigan, United States
Mercy Medical Center-West Lakes
🇺🇸
West Des Moines, Iowa, United States
Medical Oncology and Hematology Associates-West Des Moines
🇺🇸
Clive, Iowa, United States
Smilow Cancer Hospital Care Center at Saint Francis
🇺🇸
Hartford, Connecticut, United States
Reid Health
🇺🇸
Richmond, Indiana, United States
Good Samaritan Regional Health Center
🇺🇸
Mount Vernon, Illinois, United States
Mercy Cancer Center-West Lakes
🇺🇸
Clive, Iowa, United States
Kootenai Cancer
🇺🇸
Sandpoint, Idaho, United States
Allegiance Health
🇺🇸
Jackson, Michigan, United States
Community Medical Hospital
🇺🇸
Missoula, Montana, United States
Southeast Nebraska Cancer Center
🇺🇸
Lincoln, Nebraska, United States
Mount Carmel Health Center West
🇺🇸
Columbus, Ohio, United States
Delaware Radiation Oncology
🇺🇸
Delaware, Ohio, United States
Pulmonary Medicine Center of Chattanooga-Hixson
🇺🇸
Hixson, Tennessee, United States
Saint Francis Cancer Center
🇺🇸
Greenville, South Carolina, United States
Oncology Hematology Care Inc-Eden Park
🇺🇸
Cincinnati, Ohio, United States
Cancer Center of Kansas - Wellington
🇺🇸
Wellington, Kansas, United States
Cancer Center of Kansas - Parsons
🇺🇸
Parsons, Kansas, United States
Cancer Center of Kansas - Pratt
🇺🇸
Pratt, Kansas, United States
Cancer Center of Kansas-Independence
🇺🇸
Independence, Kansas, United States
Associates In Womens Health
🇺🇸
Wichita, Kansas, United States
Cancer Center of Kansas-Wichita Medical Arts Tower
🇺🇸
Wichita, Kansas, United States
Cancer Center of Kansas - Dodge City
🇺🇸
Dodge City, Kansas, United States
Cancer Center of Kansas - El Dorado
🇺🇸
El Dorado, Kansas, United States
Via Christi Regional Medical Center
🇺🇸
Wichita, Kansas, United States
Cancer Center of Kansas - Winfield
🇺🇸
Winfield, Kansas, United States
Cancer Center of Kansas - Chanute
🇺🇸
Chanute, Kansas, United States
Cancer Center of Kansas-Kingman
🇺🇸
Kingman, Kansas, United States
Henry Ford Hospital
🇺🇸
Detroit, Michigan, United States
Saint John Hospital and Medical Center
🇺🇸
Detroit, Michigan, United States
Memorial Hospital Colorado Springs
🇺🇸
Colorado Springs, Colorado, United States
Poudre Valley Hospital
🇺🇸
Fort Collins, Colorado, United States
Kootenai Medical Center
🇺🇸
Coeur d'Alene, Idaho, United States
Cancer Center of Kansas - Wichita
🇺🇸
Wichita, Kansas, United States
Commonwealth Cancer Center-Corbin
🇺🇸
Corbin, Kentucky, United States
Wayne State University/Karmanos Cancer Institute
🇺🇸
Detroit, Michigan, United States
Beaumont Hospital-Dearborn
🇺🇸
Dearborn, Michigan, United States
Jewish Hospital Medical Center South
🇺🇸
Shepherdsville, Kentucky, United States
Weisberg Cancer Treatment Center
🇺🇸
Farmington Hills, Michigan, United States
Hurley Medical Center
🇺🇸
Flint, Michigan, United States
Saint Mary Mercy Hospital
🇺🇸
Livonia, Michigan, United States
Saint Joseph Mercy Oakland
🇺🇸
Pontiac, Michigan, United States
Saint Joseph Mercy Port Huron
🇺🇸
Port Huron, Michigan, United States
Saint Mary's of Michigan
🇺🇸
Saginaw, Michigan, United States
Freeman Health System
🇺🇸
Joplin, Missouri, United States
Mercy Hospital-Joplin
🇺🇸
Joplin, Missouri, United States
Phelps County Regional Medical Center
🇺🇸
Rolla, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸
Saint Louis, Missouri, United States
Saint John's Clinic-Rolla-Cancer and Hematology
🇺🇸
Rolla, Missouri, United States
Saint Louis Cancer and Breast Institute-South City
🇺🇸
Saint Louis, Missouri, United States
Billings Clinic Cancer Center
🇺🇸
Billings, Montana, United States
Montana Cancer Consortium NCORP
🇺🇸
Billings, Montana, United States
CHI Health Saint Francis
🇺🇸
Grand Island, Nebraska, United States
Heartland Hematology and Oncology
🇺🇸
Kearney, Nebraska, United States
CHI Health Good Samaritan
🇺🇸
Kearney, Nebraska, United States
Nebraska Hematology and Oncology
🇺🇸
Lincoln, Nebraska, United States
Faith Regional Medical Offices West
🇺🇸
Norfolk, Nebraska, United States
Great Plains Regional Medical Center
🇺🇸
North Platte, Nebraska, United States
Midlands Community Hospital
🇺🇸
Papillion, Nebraska, United States
Regional West Medical Center
🇺🇸
Scottsbluff, Nebraska, United States
Dartmouth Hitchcock Medical Center
🇺🇸
Lebanon, New Hampshire, United States
Norris Cotton Cancer Center-Manchester
🇺🇸
Manchester, New Hampshire, United States
Norris Cotton Cancer Center-Nashua
🇺🇸
Nashua, New Hampshire, United States
Orange Regional Medical Center
🇺🇸
Middletown, New York, United States
Asheville Hematology-Oncology Associates
🇺🇸
Asheville, North Carolina, United States
Park Ridge Hospital Breast Health Center
🇺🇸
Hendersonville, North Carolina, United States
Strecker Cancer Center-Belpre
🇺🇸
Belpre, Ohio, United States
Miami Valley Hospital South
🇺🇸
Centerville, Ohio, United States
Adena Regional Medical Center
🇺🇸
Chillicothe, Ohio, United States
Oncology Hematology Care Inc-Mercy West
🇺🇸
Cincinnati, Ohio, United States
Good Samaritan Hospital - Cincinnati
🇺🇸
Cincinnati, Ohio, United States
Oncology Hematology Care Inc - Anderson
🇺🇸
Cincinnati, Ohio, United States
Oncology Hematology Care Inc-Kenwood
🇺🇸
Cincinnati, Ohio, United States
Bethesda North Hospital
🇺🇸
Cincinnati, Ohio, United States
Oncology Hematology Care Inc-Blue Ash
🇺🇸
Cincinnati, Ohio, United States
TriHealth Cancer Institute-Westside
🇺🇸
Cincinnati, Ohio, United States
TriHealth Cancer Institute-Anderson
🇺🇸
Cincinnati, Ohio, United States
Columbus Oncology and Hematology Associates Inc
🇺🇸
Columbus, Ohio, United States
Columbus NCI Community Oncology Research Program
🇺🇸
Columbus, Ohio, United States
The Mark H Zangmeister Center
🇺🇸
Columbus, Ohio, United States
Doctors Hospital
🇺🇸
Columbus, Ohio, United States
Good Samaritan Hospital - Dayton
🇺🇸
Dayton, Ohio, United States
Miami Valley Hospital
🇺🇸
Dayton, Ohio, United States
Samaritan North Health Center
🇺🇸
Dayton, Ohio, United States
Delaware Health Center-Grady Cancer Center
🇺🇸
Delaware, Ohio, United States
Grady Memorial Hospital
🇺🇸
Delaware, Ohio, United States
Oncology Hematology Care Inc-Healthplex
🇺🇸
Fairfield, Ohio, United States
Blanchard Valley Hospital
🇺🇸
Findlay, Ohio, United States
Atrium Medical Center-Middletown Regional Hospital
🇺🇸
Franklin, Ohio, United States
Wayne Hospital
🇺🇸
Greenville, Ohio, United States
Fairfield Medical Center
🇺🇸
Lancaster, Ohio, United States
Marietta Memorial Hospital
🇺🇸
Marietta, Ohio, United States
Knox Community Hospital
🇺🇸
Mount Vernon, Ohio, United States
Newark Radiation Oncology
🇺🇸
Newark, Ohio, United States
Southern Ohio Medical Center
🇺🇸
Portsmouth, Ohio, United States
Springfield Regional Cancer Center
🇺🇸
Springfield, Ohio, United States
Springfield Regional Medical Center
🇺🇸
Springfield, Ohio, United States
Flower Hospital
🇺🇸
Sylvania, Ohio, United States
Saint Ann's Hospital
🇺🇸
Westerville, Ohio, United States
Wright-Patterson Medical Center
🇺🇸
Wright-Patterson Air Force Base, Ohio, United States
Genesis Healthcare System Cancer Care Center
🇺🇸
Zanesville, Ohio, United States
Saint Francis Hospital
🇺🇸
Federal Way, Washington, United States
Memorial Hospital
🇺🇸
Chattanooga, Tennessee, United States
Memorial GYN Plus
🇺🇸
Ooltewah, Tennessee, United States
Harrison HealthPartners Hematology and Oncology-Bremerton
🇺🇸
Bremerton, Washington, United States
Harrison Medical Center
🇺🇸
Bremerton, Washington, United States
Saint Clare Hospital
🇺🇸
Lakewood, Washington, United States
Saint Elizabeth Hospital
🇺🇸
Enumclaw, Washington, United States
Harrison HealthPartners Hematology and Oncology-Poulsbo
🇺🇸
Poulsbo, Washington, United States
Big Horn Basin Cancer Center
🇺🇸
Cody, Wyoming, United States
Franciscan Research Center-Northwest Medical Plaza
🇺🇸
Tacoma, Washington, United States
Northwest Medical Specialties PLLC
🇺🇸
Tacoma, Washington, United States
Billings Clinic-Cody
🇺🇸
Cody, Wyoming, United States
Welch Cancer Center
🇺🇸
Sheridan, Wyoming, United States
Mercy Hospital Springfield
🇺🇸
Springfield, Missouri, United States
Saint Peter's Community Hospital
🇺🇸
Helena, Montana, United States
Saint Vincent Healthcare
🇺🇸
Billings, Montana, United States
Bozeman Deaconess Hospital
🇺🇸
Bozeman, Montana, United States
Saint James Community Hospital and Cancer Treatment Center
🇺🇸
Butte, Montana, United States
Kalispell Regional Medical Center
🇺🇸
Kalispell, Montana, United States
Central Care Cancer Center-Carrie J Babb Cancer Center
🇺🇸
Bolivar, Missouri, United States
CoxHealth Cancer Center
🇺🇸
Branson, Missouri, United States
Mayo Clinic
🇺🇸
Rochester, Minnesota, United States
Missouri Valley Cancer Consortium
🇺🇸
Omaha, Nebraska, United States
Alegent Health Immanuel Medical Center
🇺🇸
Omaha, Nebraska, United States
Hemotology and Oncology Consultants PC
🇺🇸
Omaha, Nebraska, United States
Alegent Health Bergan Mercy Medical Center
🇺🇸
Omaha, Nebraska, United States
Oncology Hematology West
🇺🇸
Omaha, Nebraska, United States
Alegent Health Lakeside Hospital
🇺🇸
Omaha, Nebraska, United States
Oncology Hematology West PC
🇺🇸
Omaha, Nebraska, United States
Creighton University Medical Center
🇺🇸
Omaha, Nebraska, United States
SWOG
🇺🇸
Portland, Oregon, United States
Jewish Hospital
🇺🇸
Louisville, Kentucky, United States
Alegent Health Mercy Hospital
🇺🇸
Council Bluffs, Iowa, United States
University of California Davis Comprehensive Cancer Center
🇺🇸
Sacramento, California, United States
University of Colorado Cancer Center - Anschutz Cancer Pavilion
🇺🇸
Aurora, Colorado, United States
Saints Mary and Elizabeth Hospital
🇺🇸
Louisville, Kentucky, United States
Saint Joseph Mercy Hospital
🇺🇸
Ann Arbor, Michigan, United States
Jewish Hospital Medical Center Northeast
🇺🇸
Louisville, Kentucky, United States
Medical Oncology and Hematology Associates-Laurel
🇺🇸
Des Moines, Iowa, United States
Mercy Medical Center - Des Moines
🇺🇸
Des Moines, Iowa, United States
Saint Joseph Radiation Oncology Resource Center
🇺🇸
Lexington, Kentucky, United States
Saint Joseph Hospital East
🇺🇸
Lexington, Kentucky, United States
Cancer Center of Kansas - Fort Scott
🇺🇸
Fort Scott, Kansas, United States
Lawrence Memorial Hospital
🇺🇸
Lawrence, Kansas, United States
Cancer Center of Kansas-Liberal
🇺🇸
Liberal, Kansas, United States
Highline Medical Center-Main Campus
🇺🇸
Burien, Washington, United States
Cancer Center of Kansas - Newton
🇺🇸
Newton, Kansas, United States
Cancer Center of Kansas - Salina
🇺🇸
Salina, Kansas, United States
Oncology Hematology Care Inc-Crestview
🇺🇸
Crestview Hills, Kentucky, United States