Atezolizumab in Treating Patients With Recurrent BCG-Unresponsive Non-muscle Invasive Bladder Cancer

Phase 2

Completed

Conditions: Recurrent Bladder Urothelial Carcinoma
Stage 0a Bladder Urothelial Carcinoma AJCC v6 and v7
Stage 0is Bladder Urothelial Carcinoma AJCC v6 and v7
Stage I Bladder Urothelial Carcinoma AJCC v6 and v7

Interventions: Drug: Atezolizumab

Registration Number: NCT02844816

Lead Sponsor: National Cancer Institute (NCI)

Brief Summary: This phase II trial studies how well atezolizumab works in treating patients with non-muscle invasive bladder cancer that has come back (recurrent) and has not responded to treatment (refractory) with Bacillus Calmette-Guerin (BCG). Immunotherapy with monoclonal antibodies, such as atezolizumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread.

Detailed Description: PRIMARY OBJECTIVE:

I. To estimate complete response at 25 weeks after registration for those with a carcinoma in situ (CIS) component and to evaluate event-free survival at 18 months in patients with BCG-unresponsive high-risk non-muscle invasive bladder cancer (Ta/T1/CIS) treated with atezolizumab.

SECONDARY OBJECTIVES:

I. To estimate event-free survival at 18 months for the subset of patients with papillary cancer (Ta/T1).

II. To estimate progression-free survival, cystectomy-free survival, bladder cancer-specific survival, overall survival in all patients.

ADDITIONAL OBJECTIVES:

I. To estimate the level of agreement between local and central pathology review in terms of recurrence (for all patients) and complete response (for the CIS subset).

II. To identify markers that predict response to atezolizumab in the CIS population and that are associated with event-free survival (EFS) in patients with Ta/T1/CIS BCG-unresponsive non-muscle invasive bladder cancer. The following markers will be tested:

IIIa. Expression of PD-L1 and CD8 by immunohistochemistry (IHC). IIIb. Expression of immune signatures by ribonucleic acid (RNA)-sequencing (RNA-seq).

IIIc. Peripheral immune response by mass cytometry (CyTOF) and TruCulture.

OUTLINE:

Patients receive atezolizumab intravenously (IV) over 60 minutes on day 1. Treatment repeats every 21 days for up to 17 cycles (51 weeks) in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 12 weeks for 2 years and then every 24 weeks for 3 years.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 172

Inclusion Criteria

Patients must have histologically proven, recurrent, non-muscle invasive urothelial carcinoma of the bladder within 60 days prior to registration; the carcinoma must be stage T1 high-grade, stage CIS, or stage Ta high-grade
Patients with mixed urothelial carcinoma and a glandular and/or squamous component will be eligible for the trial, but the presence of other histologic variants, pure adenocarcinoma, or pure squamous cell carcinoma, or pure squamous carcinoma in situ will make a patient ineligible
Patients must have had all visible tumor resected completely within 60 days prior to registration; CIS disease is not expected to be completely excised; all patients must have tumor tissue from the histologic diagnosis of recurrence available for central pathology review submission; failure to submit these materials will make the patient ineligible for this study
Patients must have had cystoscopy confirming no visible papillary tumor within 21 days prior to registration; (CIS disease is not expected to have been completely excised); if the transurethral resection of bladder tumor (TURBT) or bladder biopsy falls within 21 days of registration it will fulfill this criterion
Patients must have had urine cytology within 21 days prior to registration; cytology for patients with CIS component is not expected to be negative for malignant cells; if the cytology for male patients with only Ta/T1 disease in the absence of CIS is positive for malignant cells, patient must have had a biopsy of the prostatic urethra within the previous six months
All patients with T1 urothelial carcinoma at study entry must undergo re-TURBT within 60 days prior to registration, and must have evidence of uninvolved muscularis propria in the pathologic specimen from either the first or the second TURBT; tissue from the re-resection must be submitted for central review in addition to the tissue from the first TURBT; the TURBT that identified the recurrent T1 disease may have taken place more than 60 days prior to registration but not more than 120 days; patients with high grade Ta or CIS do not require a re-TURBT, but if this is performed at the discretion of the treating physician, the second TURBT must be within 60 days of registration; there is no requirement for muscularis propria in the specimen of Ta/CIS patients, but the tissue from the first and second TURBTs must be submitted for central review; if a patient with Ta/T1 disease undergoes repeat TURBT, the patient will be stratified as having CIS if there is CIS on either TURBT
Patients must not have had urothelial carcinoma in the prostatic urethra within the previous 24 months or muscle invasive urothelial carcinoma of the bladder at any time; patients with prior urothelial carcinoma in the upper urinary tract within the previous 24 months will only be eligible if they had =< T1 carcinoma and were treated with nephroureterectomy; patients must have a computed tomography (CT) or magnetic resonance imaging (MRI) (including CT-intravenous pyelogram [IVP], CT-urogram or MR-urogram) of the abdomen and pelvis to rule out upper tract malignancy and intra-abdominal metastases within 90 days prior to registration; if a patient cannot tolerate intravenous contrast, a retrograde pyelogram should be performed within 90 days prior to registration
Patients must be deemed unfit for radical cystectomy by the treating physician, or the patient must refuse radical cystectomy, which is considered standard of care for these patients; the reason for patients not to undergo cystectomy will be clearly documented
Patients must be BCG-unresponsive; a patient is BCG-unresponsive if they meet one or more of the following criteria:
- Patient has persistent or recurrent high-grade Ta/CIS urothelial carcinoma after completing therapy with at least induction BCG (>= 5 doses) and first round maintenance (>= 2 doses) or second induction BCG (>= 2 doses); both rounds of BCG must have been administered within a 12 month period; these patients must have either had high-grade Ta tumors and did not achieve a disease-free state for more than 6 months following last dose of BCG, or they had CIS and did not achieve a CR; S1605 registration must occur within 9 months of the last dose of BCG
  - If a patient does not meet these criteria only because the last dose of BCG was more than 9 months ago, the patient may become eligible if he/she shows histologically proven high-grade recurrence after an additional round of induction or maintenance BCG (>= 3 doses) within 9 months prior to registration
- Patient has persistent or recurrent high grade T1 urothelial carcinoma after completing therapy with at least induction BCG (>= 5 doses); patients with recurrent high grade T1 urothelial carcinoma after additional rounds of BCG will also be eligible, but one round of maintenance therapy or a second induction is not a pre-requisite for these patients. Trial registration must occur within 9 months of the last dose of BCG
  - If a patient does not meet these criteria only because the last dose of BCG was more than 9 months ago, the patient may become eligible if he/she shows histologically proven high grade recurrence after an additional round of induction or maintenance BCG (>= 3 doses) within 9 months prior to registration
- Patient achieves disease-free state at 6 month time point (i.e., complete response; presence of only low-grade tumor at this timepoint is still considered complete response) after induction and maintenance (or second round of induction) BCG but later experiences a high-grade Ta/T1 recurrence (with or without concomitant CIS) within 6 months after the last dose of BCG or recurrent CIS (in absence of concomitant Ta/T1 tumor) within 12 months after the last BCG dose; the time of eligibility is measured from the last dose of BCG to the time of disease recurrence; the patient must be registered on the trial within 60 days of this recurrence, or within 60 days of a re-TURBT if indicated
All adverse events associated with any prior surgery and intravesical therapy must have resolved to grade =< 2 prior to registration
Absolute neutrophil count (ANC) >= 1,500 microliter (mcL) (within 42 days prior to registration)
Platelets >= 100,000/mcL (within 42 days prior to registration)
Hemoglobin >= 9 g/dL (within 42 days prior to registration)
Total bilirubin =< 1.5 x institutional upper limit of normal (IULN) (except Gilbert's syndrome, who must have a total bilirubin < 3.0 mg/dL) (within 42 days prior to registration)
Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) =< 2 x IULN (within 42 days prior to registration)
Serum creatinine =< 1.5 ULN OR measured or calculated creatinine clearance >= 30 mL/min (within 42 days prior to registration)
Patients must have Zubrod performance status =< 2
Patients must have a baseline electrocardiograph (ECG) performed within 42 days prior to registration
Patients positive for human immunodeficiency virus (HIV) are eligible only if they have all of the following:
- A stable regimen of highly active anti-retroviral therapy (HAART)
- No requirement for concurrent antibiotics or antifungal agents for the prevention of opportunistic infections
- A CD4 count above 250 cells/mcL and an undetectable HIV viral load on standard PCR-based tests
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 be offered the opportunity to participate in specimen banking for future studies, to include translational medicine studies
Patients must be informed of the investigational nature of this study and must sign and give written informed consent in accordance with institutional and federal guidelines
As a part of the oncology patient enrollment network (OPEN) registration process the treating institution's identity is provided in order to ensure that the current (within 365 days) date of institutional review board approval for this study has been entered in the system

Exclusion Criteria

Patients must not have had prior systemic chemotherapy for bladder cancer or systemic immunotherapy, including, but not limited to interferon alfa-2b, high dose interleukin 2 (IL-2), pegylated interferon (PEG-IFN), PD-1, anti-PD-L1, intra-tumoral; patients must not have had vaccine therapies within 6 weeks prior to registration; patients must not have received or be planning to receive any of the prohibited therapies during protocol treatment; prior intravesical administration of chemotherapy, interferon, Vicinium (VB4-485), BC-819 or Instiladrin (rAd-interferon-alpha/Syn3) is allowed if all other criteria are met and the last administration was >= 30 days before registration
Patients must not be planning to receive concomitant other biologic therapy, radiation therapy, intravesical chemotherapy, surgery, or other anti-cancer therapy while on this protocol
Patients must not have received any prior radiation to the bladder for bladder cancer
Patients must not have received treatment with systemic immunosuppressive medications (including, but not limited to, prednisone, cyclophosphamide, azathioprine, methotrexate, thalidomide, and anti-tumor necrosis factor [anti-TNF] agents) within 4 weeks prior to registration; exceptions: (1) patients may have received acute, low dose, systemic immunosuppressant medications (e.g., a one-time dose of dexamethasone for nausea); (2) the use of inhaled corticosteroids and mineralocorticoids (e.g., fludrocortisone) for patients with orthostatic hypotension or adrenocortical insufficiency is allowed
Patients must not have received a live, attenuated vaccine within 4 weeks before registration or anticipation that such a live, attenuated vaccine will be required during the study and up to 5 months after the last dose of atezolizumab
- Influenza vaccination should be given during influenza season only (approximately October to March); patients must not receive live, attenuated influenza vaccine within 4 weeks prior to cycle 1, day 1 or at any time during the study
Patients must not require treatment with a RANKL inhibitor (e.g. denosumab) who cannot discontinue it before treatment with atezolizumab
Patient must not have history of idiopathic pulmonary fibrosis, pneumonitis (including drug induced), organizing pneumonia (i.e., bronchiolitis obliterans, cryptogenic organizing pneumonia, etc.), or evidence of active pneumonitis
Patients must not have an active infection requiring oral or IV antibiotics within 14 days prior to registration; patients receiving prophylactic antibiotics (e.g., for prevention of a urinary tract infection or chronic obstructive pulmonary disease) are eligible
Patients must not have severe infections within 28 days prior to registration, including but not limited to hospitalization for complications of infection, bacteremia, or severe pneumonia
Patients must not have active autoimmune disease that has required systemic treatment in past two years (i.e., with use of disease modifying agents, corticosteroids or immunosuppressive drugs); replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment; autoimmune diseases include, but are not limited to, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, vascular thrombosis associated with antiphospholipid syndrome, Wegener's granulomatosis, Sjogren's syndrome, Bell's palsy, Guillain-Barre syndrome, multiple sclerosis, autoimmune thyroid disease, vasculitis, or glomerulonephritis
Patients must not have undergone prior allogeneic bone marrow transplantation or prior solid organ transplantation
Patient must not have active tuberculosis
Patients must not have active hepatitis B (chronic or acute) or active hepatitis C infection
- Patients with past or resolved hepatitis B infection (defined as having a negative hepatitis B surface antigen [HBsAg] test and a positive anti-HBc [antibody to hepatitis B core antigen] antibody test) are eligible
- Patients positive for hepatitis C virus (HCV) antibody are eligible only if polymerase chain reaction (PCR) is negative for HCV RNA
Patients must not be pregnant or nursing due to the potential teratogenic side effects of the protocol treatment; administration of atezolizumab may have an adverse effect on pregnancy and poses a risk to the human fetus, including embryo-lethality; women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation, and for 5 months (150 days) after the last dose of study agent; a woman is considered to be of "reproductive potential" if she has had menses at any time in the preceding 12 consecutive months; should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately
Due to the potential drug reaction with atezolizumab, patients must not be known to be allergic to Chinese hamster egg or ovaries

Study & Design

Study Type: INTERVENTIONAL

Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Treatment (atezolizumab)	Atezolizumab	Patients receive atezolizumab IV over 60 minutes on day 1. Treatment repeats every 21 days for up to 17 cycles (51 weeks) in the absence of disease progression or unacceptable toxicity.

Primary Outcome Measures

Name	Time	Method
Event-free Survival (EFS)	18 months	To evaluate event-free survival at 18 months in patients with BCG-unresponsive high-risk non-muscle invasive bladder cancer (Ta/T1/CIS) treated with atezolizumab. Event-Free Survival is defined as time from date of registration to first documentation of event. Participants last known to be alive and not to have recurred are censored at the date of last contact. An event was defined as the first occurrence of any of the following: biopsy-proven high-grade bladder cancer (including persistent CIS at 3 and/or 6 months); high-grade upper tract urothelial carcinoma; high-grade urothelial carcinoma of the prostatic urethra; muscle-invasive disease; clinical evidence of metastatic disease; or death due to any cause.
Complete Response (CR) Rate in the Subset of Patients With Carcinoma in Situ (CIS)	At 25 weeks	To estimate complete response at 25 weeks after registration for those with a CIS component. Complete Response (CR) is defined as negative biopsy for high grade disease at Week 25 (± 7 days) for the subset of patients with a CIS component at study entry, according to local pathology call. In addition, patients with a CIS component who undergo negative biopsy at Week 13 for suspicious cystoscopy and or positive cytology and have cystoscopy not suspicious for cancer and cytology not positive for malignant cells at Week 25 do not require repeat biopsy at Week 25 and will be considered to have a complete response at Week 13 and will also be counted as having a complete response at Week 25.

Secondary Outcome Measures

Name	Time	Method
Event-free Survival (EFS) in the Ta/T1 Subset	18 months	To evaluate event-free survival at 18 months in the subset of participants with papillary cancer (Ta/T1) treated with atezolizumab. Event-Free Survival is defined as time from date of registration to first documentation of event. Participants last known to be alive and not to have recurred are censored at the date of last contact. An event was defined as the first occurrence of any of the following: biopsy-proven high-grade bladder cancer (including persistent CIS at 3 and/or 6 months); high-grade upper tract urothelial carcinoma; high-grade urothelial carcinoma of the prostatic urethra; muscle-invasive disease; clinical evidence of metastatic disease; or death due to any cause.
Progression-free Survival (PFS)	18 months	To evaluate progression-free survival at 18 months in all eligible and evaluable participants. Progression-free survival (PFS) is defined as the time from registration to first evidence of biopsy-proven muscle-invasive bladder cancer (T\>=2), nodal or distant metastasis, or death from any cause. Participants without an event were censored at the date of their last cystoscopy. Estimated using Kaplan-Meier.
Time to Cystectomy	Up to 5 years	Time to cystectomy is defined as time from discontinuation of protocol therapy to time of cystectomy.
Bladder Cancer-Specific Survival	3 years	To evaluate bladder cancer-specific survival at 3 years in all eligible and evaluable participants. Bladder cancer-specific survival is defined as the time from registration to death due to bladder cancer. Participants without bladder cancer death are censored at last contact date or date of non-bladder cancer death. Estimated using Kaplan-Meier.
Three-Year Overall Survival	3 years	Overall survival (OS) is defined as the time from registration to the date of death due to any cause. Participants last known to be alive are censored at the date of last contact.

Trial Locations

Locations (272): The University of Kansas Cancer Center - Olathe
🇺🇸
Olathe, Kansas, United States
Cancer Hematology Centers - Flint
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Flint, Michigan, United States
Southern Cancer Center PC-Daphne
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Daphne, Alabama, United States
Southern Cancer Center PC-Mobile
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Mobile, Alabama, United States
Southern Cancer Center PC-Providence
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Mobile, Alabama, United States
Southern Cancer Center PC-Springhill
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Mobile, Alabama, United States
Mayo Clinic in Arizona
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Scottsdale, Arizona, United States
University of Arizona Cancer Center-Orange Grove Campus
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Tucson, Arizona, United States
Banner University Medical Center - Tucson
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Tucson, Arizona, United States
University of Arizona Cancer Center-North Campus
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Tucson, Arizona, United States
John L McClellan Memorial Veterans Hospital
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Little Rock, Arkansas, United States
UC San Diego Moores Cancer Center
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La Jolla, California, United States
Los Angeles General Medical Center
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Los Angeles, California, United States
USC / Norris Comprehensive Cancer Center
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Los Angeles, California, United States
Stanford Cancer Institute Palo Alto
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Palo Alto, California, United States
Eisenhower Medical Center
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Rancho Mirage, California, United States
University of California Davis Comprehensive Cancer Center
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Sacramento, California, United States
UCSF Medical Center-Mission Bay
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San Francisco, California, United States
UCHealth University of Colorado Hospital
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Aurora, Colorado, United States
Kaiser Permanente-Franklin
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Denver, Colorado, United States
Kaiser Permanente-Rock Creek
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Lafayette, Colorado, United States
Kaiser Permanente-Lone Tree
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Lone Tree, Colorado, United States
Greenwich Hospital
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Greenwich, Connecticut, United States
Yale University
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New Haven, Connecticut, United States
Veterans Affairs Connecticut Healthcare System-West Haven Campus
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West Haven, Connecticut, United States
Delaware Clinical and Laboratory Physicians PA
🇺🇸
Newark, Delaware, United States
Helen F Graham Cancer Center
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Newark, Delaware, United States
Medical Oncology Hematology Consultants PA
🇺🇸
Newark, Delaware, United States
Christiana Care Health System-Christiana Hospital
🇺🇸
Newark, Delaware, United States
Christiana Care Health System-Wilmington Hospital
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Wilmington, Delaware, United States
MedStar Washington Hospital Center
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Washington, District of Columbia, United States
George Washington University Medical Center
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Washington, District of Columbia, United States
Mount Sinai Comprehensive Cancer Center at Aventura
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Aventura, Florida, United States
University of Florida Health Science Center - Gainesville
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Gainesville, Florida, United States
Mount Sinai Medical Center
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Miami Beach, Florida, United States
Indian River Medical Center
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Vero Beach, Florida, United States
Emory University Hospital/Winship Cancer Institute
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Atlanta, Georgia, United States
Atlanta VA Medical Center
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Decatur, Georgia, United States
Lewis Cancer and Research Pavilion at Saint Joseph's/Candler
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Savannah, Georgia, United States
Pali Momi Medical Center
🇺🇸
'Aiea, Hawaii, United States
Hawaii Cancer Care Inc - Waterfront Plaza
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Honolulu, Hawaii, United States
Island Urology
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Honolulu, Hawaii, United States
Queen's Cancer Cenrer - POB I
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Honolulu, Hawaii, United States
Queen's Medical Center
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Honolulu, Hawaii, United States
Straub Clinic and Hospital
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Honolulu, Hawaii, United States
University of Hawaii Cancer Center
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Honolulu, Hawaii, United States
Queen's Cancer Center - Kuakini
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Honolulu, Hawaii, United States
Kapiolani Medical Center for Women and Children
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Honolulu, Hawaii, United States
Saint Alphonsus Cancer Care Center-Boise
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Boise, Idaho, United States
Saint Luke's Cancer Institute - Boise
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Boise, Idaho, United States
Saint Alphonsus Cancer Care Center-Caldwell
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Caldwell, Idaho, United States
Walter Knox Memorial Hospital
🇺🇸
Emmett, Idaho, United States
Idaho Urologic Institute-Meridian
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Meridian, Idaho, United States
Saint Luke's Cancer Institute - Meridian
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Meridian, Idaho, United States
Saint Alphonsus Cancer Care Center-Nampa
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Nampa, Idaho, United States
Saint Luke's Cancer Institute - Twin Falls
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Twin Falls, Idaho, United States
Rush - Copley Medical Center
🇺🇸
Aurora, Illinois, United States
Illinois CancerCare-Bloomington
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Bloomington, Illinois, United States
Illinois CancerCare-Canton
🇺🇸
Canton, Illinois, United States
Illinois CancerCare-Carthage
🇺🇸
Carthage, Illinois, United States
Centralia Oncology Clinic
🇺🇸
Centralia, Illinois, United States
Northwestern University
🇺🇸
Chicago, Illinois, United States
Carle at The Riverfront
🇺🇸
Danville, Illinois, United States
Cancer Care Specialists of Illinois - Decatur
🇺🇸
Decatur, Illinois, United States
Decatur Memorial Hospital
🇺🇸
Decatur, Illinois, United States
Carle Physician Group-Effingham
🇺🇸
Effingham, Illinois, United States
Crossroads Cancer Center
🇺🇸
Effingham, Illinois, United States
Elmhurst Memorial Hospital
🇺🇸
Elmhurst, Illinois, United States
Illinois CancerCare-Eureka
🇺🇸
Eureka, Illinois, United States
Illinois CancerCare-Galesburg
🇺🇸
Galesburg, Illinois, United States
Edward Hines Jr VA Hospital
🇺🇸
Hines, Illinois, United States
Illinois CancerCare-Kewanee Clinic
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Kewanee, Illinois, United States
Illinois CancerCare-Macomb
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Macomb, Illinois, United States
Carle Physician Group-Mattoon/Charleston
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Mattoon, Illinois, United States
Loyola University Medical Center
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Maywood, Illinois, United States
Good Samaritan Regional Health Center
🇺🇸
Mount Vernon, Illinois, United States
Edward Hospital/Cancer Center
🇺🇸
Naperville, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸
Ottawa, Illinois, United States
Illinois CancerCare-Pekin
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Pekin, Illinois, United States
Illinois CancerCare-Peoria
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Peoria, Illinois, United States
Methodist Medical Center of Illinois
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Peoria, Illinois, United States
OSF Saint Francis Medical Center
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Peoria, Illinois, United States
Illinois CancerCare-Peru
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Peru, Illinois, United States
Edward Hospital/Cancer Center?Plainfield
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Plainfield, Illinois, United States
Illinois CancerCare-Princeton
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Princeton, Illinois, United States
Southern Illinois University School of Medicine
🇺🇸
Springfield, Illinois, United States
Springfield Clinic
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Springfield, Illinois, United States
Springfield Memorial Hospital
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Springfield, Illinois, United States
Carle Cancer Center
🇺🇸
Urbana, Illinois, United States
The Carle Foundation Hospital
🇺🇸
Urbana, Illinois, United States
Rush-Copley Healthcare Center
🇺🇸
Yorkville, Illinois, United States
Indiana University/Melvin and Bren Simon Cancer Center
🇺🇸
Indianapolis, Indiana, United States
Community Cancer Center East
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Indianapolis, Indiana, United States
Community Cancer Center South
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Indianapolis, Indiana, United States
Community Cancer Center North
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Indianapolis, Indiana, United States
Community Howard Regional Health
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Kokomo, Indiana, United States
Reid Health
🇺🇸
Richmond, Indiana, United States
Cancer Center of Kansas - Chanute
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Chanute, Kansas, United States
Cancer Center of Kansas - Dodge City
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Dodge City, Kansas, United States
Cancer Center of Kansas - El Dorado
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El Dorado, Kansas, United States
Cancer Center of Kansas - Fort Scott
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Fort Scott, Kansas, United States
HaysMed
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Hays, Kansas, United States
Cancer Center of Kansas-Independence
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Independence, Kansas, United States
University of Kansas Cancer Center
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Kansas City, Kansas, United States
Cancer Center of Kansas-Kingman
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Kingman, Kansas, United States
Lawrence Memorial Hospital
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Lawrence, Kansas, United States
Cancer Center of Kansas-Liberal
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Liberal, Kansas, United States
Cancer Center of Kansas-Manhattan
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Manhattan, Kansas, United States
Cancer Center of Kansas - McPherson
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McPherson, Kansas, United States
Cancer Center of Kansas - Newton
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Newton, Kansas, United States
Cancer Center of Kansas - Parsons
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Parsons, Kansas, United States
Ascension Via Christi - Pittsburg
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Pittsburg, Kansas, United States
Cancer Center of Kansas - Pratt
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Pratt, Kansas, United States
Cancer Center of Kansas - Salina
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Salina, Kansas, United States
Salina Regional Health Center
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Salina, Kansas, United States
University of Kansas Health System Saint Francis Campus
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Topeka, Kansas, United States
Cancer Center of Kansas - Wellington
🇺🇸
Wellington, Kansas, United States
University of Kansas Hospital-Westwood Cancer Center
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Westwood, Kansas, United States
Cancer Center of Kansas-Wichita Medical Arts Tower
🇺🇸
Wichita, Kansas, United States
Ascension Via Christi Hospitals Wichita
🇺🇸
Wichita, Kansas, United States
Cancer Center of Kansas - Wichita
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Wichita, Kansas, United States
Cancer Center of Kansas - Winfield
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Winfield, Kansas, United States
University of Kentucky/Markey Cancer Center
🇺🇸
Lexington, Kentucky, United States
East Jefferson General Hospital
🇺🇸
Metairie, Louisiana, United States
LSU Healthcare Network / Metairie Multi-Specialty Clinic
🇺🇸
Metairie, Louisiana, United States
Louisiana State University Health Science Center
🇺🇸
New Orleans, Louisiana, United States
LSU Health Sciences Center at Shreveport
🇺🇸
Shreveport, Louisiana, United States
Johns Hopkins University/Sidney Kimmel Cancer Center
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Baltimore, Maryland, United States
Boston Medical Center
🇺🇸
Boston, Massachusetts, United States
Lowell General Hospital
🇺🇸
Lowell, Massachusetts, United States
Trinity Health Saint Joseph Mercy Hospital Ann Arbor
🇺🇸
Ann Arbor, Michigan, United States
Trinity Health IHA Medical Group Hematology Oncology - Brighton
🇺🇸
Brighton, Michigan, United States
Trinity Health Medical Center - Brighton
🇺🇸
Brighton, Michigan, United States
Trinity Health IHA Medical Group Hematology Oncology - Canton
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Canton, Michigan, United States
Trinity Health Medical Center - Canton
🇺🇸
Canton, Michigan, United States
Caro Cancer Center
🇺🇸
Caro, Michigan, United States
Chelsea Hospital
🇺🇸
Chelsea, Michigan, United States
Trinity Health IHA Medical Group Hematology Oncology - Chelsea Hospital
🇺🇸
Chelsea, Michigan, United States
Hematology Oncology Consultants-Clarkston
🇺🇸
Clarkston, Michigan, United States
Newland Medical Associates-Clarkston
🇺🇸
Clarkston, Michigan, United States
Michigan State University Clinical Center
🇺🇸
East Lansing, Michigan, United States
Genesee Hematology Oncology PC
🇺🇸
Flint, Michigan, United States
Genesys Hurley Cancer Institute
🇺🇸
Flint, Michigan, United States
University of Michigan Health - Sparrow Lansing
🇺🇸
Lansing, Michigan, United States
Saint Mary's Oncology/Hematology Associates of Marlette
🇺🇸
Marlette, Michigan, United States
Newland Medical Associates-Pontiac
🇺🇸
Pontiac, Michigan, United States
Trinity Health Saint Joseph Mercy Oakland Hospital
🇺🇸
Pontiac, Michigan, United States
MyMichigan Medical Center Saginaw
🇺🇸
Saginaw, Michigan, United States
Oncology Hematology Associates of Saginaw Valley PC
🇺🇸
Saginaw, Michigan, United States
Saint Mary's Oncology/Hematology Associates of West Branch
🇺🇸
West Branch, Michigan, United States
Huron Gastroenterology PC
🇺🇸
Ypsilanti, Michigan, United States
Trinity Health IHA Medical Group Hematology Oncology Ann Arbor Campus
🇺🇸
Ypsilanti, Michigan, United States
Fairview Ridges Hospital
🇺🇸
Burnsville, Minnesota, United States
Essentia Health - Deer River Clinic
🇺🇸
Deer River, Minnesota, United States
Essentia Health Cancer Center
🇺🇸
Duluth, Minnesota, United States
Essentia Health Saint Mary's Medical Center
🇺🇸
Duluth, Minnesota, United States
Miller-Dwan Hospital
🇺🇸
Duluth, Minnesota, United States
Saint Luke's Hospital of Duluth
🇺🇸
Duluth, Minnesota, United States
Fairview Southdale Hospital
🇺🇸
Edina, Minnesota, United States
Essentia Health Hibbing Clinic
🇺🇸
Hibbing, Minnesota, United States
Coborn Cancer Center at Saint Cloud Hospital
🇺🇸
Saint Cloud, Minnesota, United States
Saint Cloud Hospital
🇺🇸
Saint Cloud, Minnesota, United States
Park Nicollet Clinic - Saint Louis Park
🇺🇸
Saint Louis Park, Minnesota, United States
Essentia Health Virginia Clinic
🇺🇸
Virginia, Minnesota, United States
Fairview Lakes Medical Center
🇺🇸
Wyoming, Minnesota, United States
Parkland Health Center-Bonne Terre
🇺🇸
Bonne Terre, Missouri, United States
Saint Francis Medical Center
🇺🇸
Cape Girardeau, Missouri, United States
Southeast Cancer Center
🇺🇸
Cape Girardeau, Missouri, United States
MU Health - University Hospital/Ellis Fischel Cancer Center
🇺🇸
Columbia, Missouri, United States
OptumCare Cancer Care at MountainView
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Town Center
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Central Valley
🇺🇸
Las Vegas, Nevada, United States
Renown Regional Medical Center
🇺🇸
Reno, Nevada, United States
Robert Wood Johnson University Hospital Somerset
🇺🇸
Somerville, New Jersey, United States
Kansas City Veterans Affairs Medical Center
🇺🇸
Kansas City, Missouri, United States
Sainte Genevieve County Memorial Hospital
🇺🇸
Sainte Genevieve, Missouri, United States
Missouri Baptist Sullivan Hospital
🇺🇸
Sullivan, Missouri, United States
BJC Outpatient Center at Sunset Hills
🇺🇸
Sunset Hills, Missouri, United States
Missouri Baptist Medical Center
🇺🇸
Saint Louis, Missouri, United States
Benefis Sletten Cancer Institute
🇺🇸
Great Falls, Montana, United States
Saint Patrick Hospital - Community Hospital
🇺🇸
Missoula, Montana, United States
Nebraska Medicine-Village Pointe
🇺🇸
Omaha, Nebraska, United States
University of Nebraska Medical Center
🇺🇸
Omaha, Nebraska, United States
Cancer and Blood Specialists-Henderson
🇺🇸
Henderson, Nevada, United States
Ann M Wierman MD LTD
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Northwest
🇺🇸
Las Vegas, Nevada, United States
Roswell Park Cancer Institute
🇺🇸
Buffalo, New York, United States
Mount Sinai West
🇺🇸
New York, New York, United States
NYP/Weill Cornell Medical Center
🇺🇸
New York, New York, United States
University of Rochester
🇺🇸
Rochester, New York, United States
State University of New York Upstate Medical University
🇺🇸
Syracuse, New York, United States
Southeastern Medical Oncology Center-Clinton
🇺🇸
Clinton, North Carolina, United States
Southeastern Medical Oncology Center-Goldsboro
🇺🇸
Goldsboro, North Carolina, United States
Wayne Memorial Hospital
🇺🇸
Goldsboro, North Carolina, United States
Southeastern Medical Oncology Center-Jacksonville
🇺🇸
Jacksonville, North Carolina, United States
WG Hefner VA Medical Center
🇺🇸
Salisbury, North Carolina, United States
Wake Forest University Health Sciences
🇺🇸
Winston-Salem, North Carolina, United States
Sanford Bismarck Medical Center
🇺🇸
Bismarck, North Dakota, United States
Sanford Broadway Medical Center
🇺🇸
Fargo, North Dakota, United States
Miami Valley Hospital North
🇺🇸
Dayton, Ohio, United States
Oklahoma Cancer Specialists and Research Institute-Tulsa
🇺🇸
Tulsa, Oklahoma, United States
Saint Alphonsus Cancer Care Center-Baker City
🇺🇸
Baker City, Oregon, United States
Legacy Mount Hood Medical Center
🇺🇸
Gresham, Oregon, United States
Saint Alphonsus Cancer Care Center-Ontario
🇺🇸
Ontario, Oregon, United States
Legacy Good Samaritan Hospital and Medical Center
🇺🇸
Portland, Oregon, United States
Sanford Roger Maris Cancer Center
🇺🇸
Fargo, North Dakota, United States
Dayton Physician LLC - Englewood
🇺🇸
Dayton, Ohio, United States
Kettering Medical Center
🇺🇸
Kettering, Ohio, United States
University of Oklahoma Health Sciences Center
🇺🇸
Oklahoma City, Oklahoma, United States
Saint Rita's Medical Center
🇺🇸
Lima, Ohio, United States
Mercy Hospital Oklahoma City
🇺🇸
Oklahoma City, Oklahoma, United States
Legacy Meridian Park Hospital
🇺🇸
Tualatin, Oregon, United States
Christiana Care Health System-Concord Health Center
🇺🇸
Chadds Ford, Pennsylvania, United States
Allegheny General Hospital
🇺🇸
Pittsburgh, Pennsylvania, United States
Prisma Health Cancer Institute - Spartanburg
🇺🇸
Boiling Springs, South Carolina, United States
Prisma Health Cancer Institute - Laurens
🇺🇸
Clinton, South Carolina, United States
Prisma Health Cancer Institute - Easley
🇺🇸
Easley, South Carolina, United States
Prisma Health Cancer Institute - Butternut
🇺🇸
Greenville, South Carolina, United States
Prisma Health Cancer Institute - Faris
🇺🇸
Greenville, South Carolina, United States
Prisma Health Greenville Memorial Hospital
🇺🇸
Greenville, South Carolina, United States
Prisma Health Cancer Institute - Eastside
🇺🇸
Greenville, South Carolina, United States
Prisma Health Cancer Institute - Greer
🇺🇸
Greer, South Carolina, United States
Prisma Health Cancer Institute - Seneca
🇺🇸
Seneca, South Carolina, United States
Sanford Cancer Center Oncology Clinic
🇺🇸
Sioux Falls, South Dakota, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸
Sioux Falls, South Dakota, United States
University of Texas Medical Branch
🇺🇸
Galveston, Texas, United States
Baylor College of Medicine/Dan L Duncan Comprehensive Cancer Center
🇺🇸
Houston, Texas, United States
UTMB Cancer Center at Victory Lakes
🇺🇸
League City, Texas, United States
Audie L Murphy VA Hospital
🇺🇸
San Antonio, Texas, United States
University Hospital
🇺🇸
San Antonio, Texas, United States
University of Texas Health Science Center at San Antonio
🇺🇸
San Antonio, Texas, United States
Farmington Health Center
🇺🇸
Farmington, Utah, United States
Huntsman Cancer Institute/University of Utah
🇺🇸
Salt Lake City, Utah, United States
South Jordan Health Center
🇺🇸
South Jordan, Utah, United States
Centra Alan B Pearson Regional Cancer Center
🇺🇸
Lynchburg, Virginia, United States
Virginia Commonwealth University/Massey Cancer Center
🇺🇸
Richmond, Virginia, United States
Swedish Medical Center-First Hill
🇺🇸
Seattle, Washington, United States
Legacy Salmon Creek Hospital
🇺🇸
Vancouver, Washington, United States
West Virginia University Charleston Division
🇺🇸
Charleston, West Virginia, United States
Duluth Clinic Ashland
🇺🇸
Ashland, Wisconsin, United States
Aurora Cancer Care-Southern Lakes VLCC
🇺🇸
Burlington, Wisconsin, United States
Marshfield Clinic-Chippewa Center
🇺🇸
Chippewa Falls, Wisconsin, United States
Marshfield Medical Center-EC Cancer Center
🇺🇸
Eau Claire, Wisconsin, United States
Aurora Health Center-Fond du Lac
🇺🇸
Fond Du Lac, Wisconsin, United States
Aurora Health Care Germantown Health Center
🇺🇸
Germantown, Wisconsin, United States
Aurora Cancer Care-Grafton
🇺🇸
Grafton, Wisconsin, United States
Aurora BayCare Medical Center
🇺🇸
Green Bay, Wisconsin, United States
Aurora Cancer Care-Kenosha South
🇺🇸
Kenosha, Wisconsin, United States
Marshfield Medical Center - Ladysmith
🇺🇸
Ladysmith, Wisconsin, United States
University of Wisconsin Carbone Cancer Center - University Hospital
🇺🇸
Madison, Wisconsin, United States
Aurora Bay Area Medical Group-Marinette
🇺🇸
Marinette, Wisconsin, United States
Marshfield Medical Center-Marshfield
🇺🇸
Marshfield, Wisconsin, United States
Aurora Cancer Care-Milwaukee
🇺🇸
Milwaukee, Wisconsin, United States
Aurora Saint Luke's Medical Center
🇺🇸
Milwaukee, Wisconsin, United States
Aurora Sinai Medical Center
🇺🇸
Milwaukee, Wisconsin, United States
Marshfield Medical Center - Minocqua
🇺🇸
Minocqua, Wisconsin, United States
Vince Lombardi Cancer Clinic - Oshkosh
🇺🇸
Oshkosh, Wisconsin, United States
Aurora Cancer Care-Racine
🇺🇸
Racine, Wisconsin, United States
Marshfield Medical Center-Rice Lake
🇺🇸
Rice Lake, Wisconsin, United States
Vince Lombardi Cancer Clinic-Sheboygan
🇺🇸
Sheboygan, Wisconsin, United States
Marshfield Medical Center-River Region at Stevens Point
🇺🇸
Stevens Point, Wisconsin, United States
Aurora Medical Center in Summit
🇺🇸
Summit, Wisconsin, United States
Vince Lombardi Cancer Clinic-Two Rivers
🇺🇸
Two Rivers, Wisconsin, United States
Marshfield Clinic-Wausau Center
🇺🇸
Wausau, Wisconsin, United States
Aurora Cancer Care-Milwaukee West
🇺🇸
Wauwatosa, Wisconsin, United States
Aurora West Allis Medical Center
🇺🇸
West Allis, Wisconsin, United States
Marshfield Medical Center - Weston
🇺🇸
Weston, Wisconsin, United States
Marshfield Clinic - Wisconsin Rapids Center
🇺🇸
Wisconsin Rapids, Wisconsin, United States
Cross Cancer Institute
🇨🇦
Edmonton, Alberta, Canada
The Research Institute of the McGill University Health Centre (MUHC)
🇨🇦
Montreal, Quebec, Canada
Allan Blair Cancer Centre
🇨🇦
Regina, Saskatchewan, Canada