Atezolizumab, Pemetrexed Disodium, Cisplatin, and Surgery With or Without Radiation Therapy in Treating Patients With Stage I-III Pleural Malignant Mesothelioma

Phase 1

Active, not recruiting

Conditions: Biphasic Mesothelioma
Epithelioid Mesothelioma
Stage I Pleural Malignant Mesothelioma AJCC v7
Stage IA Pleural Malignant Mesothelioma AJCC v7
Stage IB Pleural Malignant Mesothelioma AJCC v7
Stage II Pleural Malignant Mesothelioma AJCC v7
Stage III Pleural Malignant Mesothelioma AJCC v7

Interventions: Drug: Atezolizumab
Drug: Cisplatin
Procedure: Extrapleural Pneumonectomy
Drug: Pemetrexed Disodium
Procedure: Pleurectomy
Radiation: Radiation Therapy

Registration Number: NCT03228537

Lead Sponsor: National Cancer Institute (NCI)

Brief Summary: This phase I pilot trial studies how well atezolizumab, pemetrexed disodium, cisplatin, and surgery with or without radiation therapy works in treating patients with stage I-III pleural malignant mesothelioma. 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. Pemetrexed disodium may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Drugs used in chemotherapy, such as cisplatin, 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. Giving atezolizumab, pemetrexed disodium, and cisplatin before surgery may make the tumor smaller and reduce the amount of normal tissue that needs to be removed. Giving atezolizumab after surgery may kill any remaining tumor cells.

Detailed Description: PRIMARY OBJECTIVE:

I. To evaluate if the regimen of neoadjuvant cisplatin-pemetrexed disodium (pemetrexed)-atezolizumab, surgery +/- radiation, then maintenance atezolizumab is feasible and safe for patients with resectable malignant pleural mesothelioma.

SECONDARY OBJECTIVES:

I. To evaluate progression free survival (both by Response Evaluation Criteria in Solid Tumors \[RECIST\] 1.1 and also using a modified RECIST for pleural tumors) in patients with resectable malignant pleural mesothelioma treated with a regimen of neoadjuvant cisplatin-pemetrexed-atezolizumab, surgery +/- radiation, followed by one year of maintenance atezolizumab.

II. To evaluate overall survival in patients with resectable malignant pleural mesothelioma treated with a regimen of neoadjuvant cisplatin-pemetrexed-atezolizumab, surgery +/- radiation, followed by one year of maintenance atezolizumab.

III. To evaluate response rate (confirmed and unconfirmed, complete and partial, both by RECIST 1.1 and also using a modified RECIST for pleural tumors) in the subset of this patient population with measurable disease.

TRANSLATIONAL MEDICINE OBJECTIVES:

I. To evaluate the association between immunohistochemical (IHC) expression of PD-L1 in tumors and clinical outcomes in mesothelioma patients treated with trimodality/bimodality therapy including atezolizumab (anti-PD-L1).

II. To evaluate the association between expression of immune-related genes identified by Immune Nanostring (depending on ribonucleic acid \[RNA\] availability) and clinical outcomes in mesothelioma patients treated with trimodality/bimodality therapy including atezolizumab.

III. To evaluate the association between multiplex immunofluorescence (IF) of up to 10 immune markers in two panels and clinical outcomes in mesothelioma patients treated with trimodality/bimodality therapy including atezolizumab.

OUTLINE:

NEOADJUVANT: Patients receive atezolizumab intravenously (IV) over 30-60 minutes, pemetrexed disodium IV over 10 minutes, and cisplatin IV over 2 hours on day 1. Cycles repeats every 21 days for 4 cycles in the absence of disease progression or unexpected toxicity.

SURGERY: Within 21-90 days after completion of neoadjuvant therapy, patients undergo extrapleural pneumonectomy (EPP) or pleurectomy/decortication (PD). Patients who undergo EPP will then undergo radiation therapy (RT).

MAINTENANCE: Within 90 days after completion of either PD or radiation (post-EPP), patients receive atezolizumab IV over 60 minutes on day 1. Treatment repeats every 21 days for up to 1 year in the absence of disease progression or unexpected toxicity.

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

Recruitment & Eligibility

Status: ACTIVE_NOT_RECRUITING

Sex: All

Target Recruitment: 28

Inclusion Criteria

STEP 1: NEOADJUVANT
Patient must have stage I-III malignant pleural mesothelioma that is deemed resectable and must be planning to undergo pleurectomy decortication (P/D) or extrapleural pneumonectomy (EPP)
Patient must have epithelioid or biphasic histology (sarcomatoid histology is excluded); histologic diagnosis and typing of mesothelioma requires at least a core needle biopsy or surgical biopsy of the pleura via thoracoscopy and small thoracotomy; cytology only will not be regarded as sufficient for the diagnosis
Patient must have computed tomography (CT) chest/abdomen/pelvis with contrast or fludeoxyglucose F-18 (FDG)-positron emission tomography (PET)/CT scan performed within 28 days prior to step 1 registration
Patients must have non-measurable or measurable disease documented by CT or magnetic resonance imaging (MRI); the CT from a combined 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 step 1 registration; non-measurable disease must be assessed within 42 days prior to step 1 registration; all disease must be assessed and documented on the RECIST 1.1 and modified RECIST baseline tumor assessment form
Patient must have undergone extended surgical staging including mediastinoscopy or endobronchial ultrasound; at minimum, samples must be obtained from the mediastinal stations 4R, 7 (subcarinal), and 4L; this surgical staging must be performed within 42 days prior to step 1 registration; patient must be T1-3 and N0-N2 (single station)
Patient must undergo video-assisted thoracoscopic surgery and diagnostic laparoscopy within 28 days prior to step 1 registration to rule out peritoneal disease spread
Patient must have consultation with a surgeon within 21 days prior to step 1 registration; the surgeon must confirm that the patient's disease is resectable by pleurectomy decortication (P/D) or extrapleural pneumonectomy (EPP) and that the patient is an appropriate candidate for the surgical procedures
Patient must not have had prior immunotherapy or chemotherapy for malignant pleural mesothelioma
Patient must have Zubrod performance status 0 or 1 documented within 28 days prior to step 1 registration
Patients requiring hearing aids or reporting hearing loss must have audiogram performed within 28 days prior to step 1 registration
Patient must have not had any major surgery or radiation within 28 days prior to step 1 registration; diagnostic thoracotomies and laparoscopies are not considered major surgeries
Patients must not have any anticancer therapy or investigational agent within 28 days prior to step 1 registration
Absolute neutrophil count (ANC) >= 1,500/mcl (documented within 28 days prior to step 1 registration)
Hemoglobin >= 9 g/dl (documented within 28 days prior to step 1 registration)
Platelets >= 100,000/mcl (documented within 28 days prior to step 1 registration)
Creatinine =< 1.5 x upper limit of normal (ULN) (documented within 28 days prior to step 1 registration)
Creatinine clearance >= 45 ml/min (documented within 28 days prior to step 1 registration)
Total bilirubin =< 1.5 x upper limit of normal (ULN) (within 28 days prior to step 1 registration)
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 3 x ULN (within 28 days prior to step 1 registration)
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 three years
Patients must not be pregnant or nursing due to the potential teratogenic side effects of the protocol treatment; women of reproductive potential and men must have agreed to use an effective contraceptive method for the duration of study treatment and for 5 months (150 days) after the last dose of atezolizumab; 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
Patient must NOT have a history of severe allergic, anaphylactic, or other hypersensitivity reactions to chimeric or humanized antibodies or fusion proteins
Patient must NOT have a known hypersensitivity or allergy to biopharmaceuticals produced in Chinese hamster ovary cells or any component of the atezolizumab formulation
Patients must not have severe infections within 28 days prior to step 1 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; this protocol includes an immunotherapy agent which can precipitate known autoimmune diseases
Patients must not have undergone prior allogeneic bone marrow transplantation or prior solid organ transplantation
Patient must not have active tuberculosis
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; this protocol includes an immunotherapy agent which can precipitate known pneumonitis
Patient must not have active (chronic or acute) hepatitis B virus (HBV) infection as evidenced by testing performed within 28 days prior to registration; patients with past or resolved HBV infection are eligible; active HBV is defined as having a positive hepatitis B surface antigen (HBsAg) test; past or resolved HBV is defined as having a negative HBsAG test and a positive total hepatitis B core antibody (HBcAb) test; patient must not have active hepatitis C virus (HCV) infection as evidenced by testing performed within 28 days prior to registration; active HCV is defined as having a positive HCV antibody test followed by a positive HCV RNA test
Patient must NOT have a known positive test for human immunodeficiency virus (HIV); patients do not need to be screened for HIV; patients with HIV are excluded due to a potential incompetent immune system and need for medications that could interfere with the treatment and immunotherapy
Patient must not have significant cardiovascular disease, such as New York Heart Association cardiac disease (class II or greater), myocardial infarction within 3 months prior to initiation of treatment, unstable arrhythmias, or unstable angina given the higher risks associated with surgical resection
Patient must not receive live, attenuated influenza vaccine within 4 weeks prior to registration or at any time during the study and until 5 months after the last dose of atezolizumab
Patient must be willing to have tissue specimens submitted for translational medicine studies
Patient must be offered the opportunity to participate in tissue and blood banking for future studies
Patient 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
STEP 2: SURGERY
Patient must have a CT of chest/abdomen with contrast or FDG-PET/CT scan within 28 days prior to step 2 registration; patients must not have evidence of progression per RECIST 1.1 or modified RECIST for pleural tumors
Patients planning to receive EPP must also be evaluated for appropriateness of radiation therapy (RT) by a radiation oncologist within 14 days prior to step 2 registration
Patients must have a Zubrod performance status of 0-1 documented within 28 days prior to step 2 registration
Patients must have postoperative predicted forced expiratory volume in 1 second (FEV1) > 35% prior to surgery obtained within 28 days prior to step 2 registration; pulmonary function tests to ascertain these values must be obtained within 28 days prior to Step 2 registration
Patients must have postoperative predicted carbon monoxide diffusing capability (DLCO) > 35% prior to surgery obtained within 28 days prior to step 2 registration; pulmonary function tests to ascertain these values must be obtained within 28 days prior to Step 2 registration
Patient must have received at least two cycles of triplet neoadjuvant therapy (all three drugs) during step 1
Patient must be registered to step 2 no less than 21 days and no more than 90 days after the end of their final cycle of neoadjuvant therapy
STEP 3: MAINTENANCE
Patient must have received either P/D or EPP and must have recovered from all effects of surgery with adequate wound healing; patients who received radiation therapy (RT) must be registered to step 3 within 90 days after discontinuing RT; patients who did not receive RT must be registered to step 3 within 90 days after surgery
Patient must have a CT of chest/abdomen/pelvis with contrast or FDG-PET/CT scan within 28 days prior to step 3 registration; patient must not have evidence of progression per RECIST 1.1 or modified RECIST for pleural tumors
Patient may have discontinued RT early due to toxicity or other reasons
Patients must have a Zubrod performance status of 0-1 documented within 28 days prior to step 3 registration
ANC > 1,500/mcl (documented within 28 days prior to step 3 registration)
Hemoglobin > 9 g/dl (documented within 28 days prior to step 3 registration)
Platelets > 100,000/mcl (documented within 28 days prior to step 3 registration)
Creatinine < 1.5 x ULN (documented within 28 days prior to step 3 registration)
Total bilirubin =< 1.5 x upper limit of normal (ULN) (within 28 days prior to step 3 registration)
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 3 x ULN (within 28 days prior to step 3 registration)

Exclusion Criteria

Not provided

Study & Design

Study Type: INTERVENTIONAL

Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Treatment (chemotherapy, surgery, RT)	Extrapleural Pneumonectomy	NEOADJUVANT: Patients receive atezolizumab IV over 30-60 minutes, pemetrexed disodium IV over 10 minutes, and cisplatin IV over 2 hours on day 1. Cycles repeats every 21 days for 4 cycles in the absence of disease progression or unexpected toxicity. SURGERY: Within 21-90 days after completion of neoadjuvant therapy, patients undergo EPP or PD. Patients who undergo EPP will then undergo RT. MAINTENANCE: Within 90 days after completion of either PD or radiation (post-EPP), patients receive atezolizumab IV over 60 minutes on day 1. Treatment repeats every 21 days for up to 1 year in the absence of disease progression or unexpected toxicity.
Treatment (chemotherapy, surgery, RT)	Pemetrexed Disodium	NEOADJUVANT: Patients receive atezolizumab IV over 30-60 minutes, pemetrexed disodium IV over 10 minutes, and cisplatin IV over 2 hours on day 1. Cycles repeats every 21 days for 4 cycles in the absence of disease progression or unexpected toxicity. SURGERY: Within 21-90 days after completion of neoadjuvant therapy, patients undergo EPP or PD. Patients who undergo EPP will then undergo RT. MAINTENANCE: Within 90 days after completion of either PD or radiation (post-EPP), patients receive atezolizumab IV over 60 minutes on day 1. Treatment repeats every 21 days for up to 1 year in the absence of disease progression or unexpected toxicity.
Treatment (chemotherapy, surgery, RT)	Pleurectomy	NEOADJUVANT: Patients receive atezolizumab IV over 30-60 minutes, pemetrexed disodium IV over 10 minutes, and cisplatin IV over 2 hours on day 1. Cycles repeats every 21 days for 4 cycles in the absence of disease progression or unexpected toxicity. SURGERY: Within 21-90 days after completion of neoadjuvant therapy, patients undergo EPP or PD. Patients who undergo EPP will then undergo RT. MAINTENANCE: Within 90 days after completion of either PD or radiation (post-EPP), patients receive atezolizumab IV over 60 minutes on day 1. Treatment repeats every 21 days for up to 1 year in the absence of disease progression or unexpected toxicity.
Treatment (chemotherapy, surgery, RT)	Radiation Therapy	NEOADJUVANT: Patients receive atezolizumab IV over 30-60 minutes, pemetrexed disodium IV over 10 minutes, and cisplatin IV over 2 hours on day 1. Cycles repeats every 21 days for 4 cycles in the absence of disease progression or unexpected toxicity. SURGERY: Within 21-90 days after completion of neoadjuvant therapy, patients undergo EPP or PD. Patients who undergo EPP will then undergo RT. MAINTENANCE: Within 90 days after completion of either PD or radiation (post-EPP), patients receive atezolizumab IV over 60 minutes on day 1. Treatment repeats every 21 days for up to 1 year in the absence of disease progression or unexpected toxicity.
Treatment (chemotherapy, surgery, RT)	Atezolizumab	NEOADJUVANT: Patients receive atezolizumab IV over 30-60 minutes, pemetrexed disodium IV over 10 minutes, and cisplatin IV over 2 hours on day 1. Cycles repeats every 21 days for 4 cycles in the absence of disease progression or unexpected toxicity. SURGERY: Within 21-90 days after completion of neoadjuvant therapy, patients undergo EPP or PD. Patients who undergo EPP will then undergo RT. MAINTENANCE: Within 90 days after completion of either PD or radiation (post-EPP), patients receive atezolizumab IV over 60 minutes on day 1. Treatment repeats every 21 days for up to 1 year in the absence of disease progression or unexpected toxicity.
Treatment (chemotherapy, surgery, RT)	Cisplatin	NEOADJUVANT: Patients receive atezolizumab IV over 30-60 minutes, pemetrexed disodium IV over 10 minutes, and cisplatin IV over 2 hours on day 1. Cycles repeats every 21 days for 4 cycles in the absence of disease progression or unexpected toxicity. SURGERY: Within 21-90 days after completion of neoadjuvant therapy, patients undergo EPP or PD. Patients who undergo EPP will then undergo RT. MAINTENANCE: Within 90 days after completion of either PD or radiation (post-EPP), patients receive atezolizumab IV over 60 minutes on day 1. Treatment repeats every 21 days for up to 1 year in the absence of disease progression or unexpected toxicity.

Primary Outcome Measures

Name	Time	Method
Feasibility of Neoadjuvant Cisplatin-Pemetrexed-Atezolizumab, Surgery +/- Radiation, and Maintenance Therapy.	Duration of treatment until first dose of maintenance therapy. Includes 21 day cycles of neoadjuvant chemo and surgery - extrapleural pneumonectomy or pleurectomy/decortication (radiation therapy for participants who received extrapleural pneumonectomy).	The number of participants who received at least two cycles of the triplet neoadjuvant therapy getting at least one dose of maintenance therapy.
Safety of Neoadjuvant Cisplatin-Pemetrexed-Atezolizumab, Surgery +/- Radiation, and Maintenance Therapy.	Duration of treatment and follow-up until death or 3 years post Step 1 registration.	The number of participants that experienced a Grade 4-5 immune-related adverse event. The regimen was considered safe if no participants experienced a Grade 4-5 immune-related AE.

Secondary Outcome Measures

Name	Time	Method
Progression Free Survival (PFS)	Duration of treatment and follow-up until death or 3 years post Step 1 registration.	From date of registration to Step 1 to date of first documentation of progression by RECIST 1.1 and modified RECIST 1.1, symptomatic deterioration, or death due to any cause. Participants last known to be alive and progression free are censored at date of last disease assessment.
Overall Survival (OS)	3 years after the last accrual	From date of initial registration to date of death due to any cause. Participants last known to be alive are censored at date of last contact.
Response Rate (RR)	Duration of treatment and follow-up until death or 3 years post Step 1 registration.	Percentage of participants with confirmed and unconfirmed, complete and partial, defined by RECIST 1.1 and mRECIST for Pleural Tumors

Trial Locations

Locations (177): Mayo Clinic Hospital in Arizona
🇺🇸
Phoenix, Arizona, United States
Mayo Clinic in Arizona
🇺🇸
Scottsdale, Arizona, United States
CHI Saint Vincent Cancer Center Hot Springs
🇺🇸
Hot Springs, Arkansas, United States
PCR Oncology
🇺🇸
Arroyo Grande, California, United States
City of Hope Comprehensive Cancer Center
🇺🇸
Duarte, California, United States
University of California Davis Comprehensive Cancer Center
🇺🇸
Sacramento, California, United States
Penrose-Saint Francis Healthcare
🇺🇸
Colorado Springs, Colorado, United States
Rocky Mountain Cancer Centers-Penrose
🇺🇸
Colorado Springs, Colorado, United States
AdventHealth Porter
🇺🇸
Denver, Colorado, United States
Mercy Medical Center
🇺🇸
Durango, Colorado, United States
Southwest Oncology PC
🇺🇸
Durango, Colorado, United States
Mountain Blue Cancer Care Center
🇺🇸
Golden, Colorado, United States
Rocky Mountain Cancer Centers-Lakewood
🇺🇸
Lakewood, Colorado, United States
Saint Anthony Hospital
🇺🇸
Lakewood, Colorado, United States
AdventHealth Littleton
🇺🇸
Littleton, Colorado, United States
Longmont United Hospital
🇺🇸
Longmont, Colorado, United States
Rocky Mountain Cancer Centers-Longmont
🇺🇸
Longmont, Colorado, United States
AdventHealth Parker
🇺🇸
Parker, Colorado, United States
Rocky Mountain Cancer Centers-Parker
🇺🇸
Parker, Colorado, United States
Saint Mary Corwin Medical Center
🇺🇸
Pueblo, Colorado, United States
Rocky Mountain Cancer Centers - Pueblo
🇺🇸
Pueblo, Colorado, United States
Rocky Mountain Cancer Centers-Thornton
🇺🇸
Thornton, Colorado, United States
Baptist MD Anderson Cancer Center
🇺🇸
Jacksonville, Florida, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸
Boise, Idaho, United States
Saint Alphonsus Cancer Care Center-Caldwell
🇺🇸
Caldwell, Idaho, United States
Kootenai Health - Coeur d'Alene
🇺🇸
Coeur d'Alene, Idaho, United States
Idaho Urologic Institute-Meridian
🇺🇸
Meridian, Idaho, United States
Saint Alphonsus Cancer Care Center-Nampa
🇺🇸
Nampa, Idaho, United States
Kootenai Clinic Cancer Services - Post Falls
🇺🇸
Post Falls, Idaho, United States
Kootenai Clinic Cancer Services - Sandpoint
🇺🇸
Sandpoint, Idaho, United States
Rush - Copley Medical Center
🇺🇸
Aurora, Illinois, United States
Illinois CancerCare-Bloomington
🇺🇸
Bloomington, Illinois, United States
Illinois CancerCare-Canton
🇺🇸
Canton, Illinois, United States
Memorial Hospital of Carbondale
🇺🇸
Carbondale, Illinois, United States
SIH Cancer Institute
🇺🇸
Carterville, Illinois, United States
Illinois CancerCare-Carthage
🇺🇸
Carthage, Illinois, United States
Centralia Oncology Clinic
🇺🇸
Centralia, 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
Illinois CancerCare-Eureka
🇺🇸
Eureka, Illinois, United States
Illinois CancerCare-Galesburg
🇺🇸
Galesburg, Illinois, United States
Western Illinois Cancer Treatment Center
🇺🇸
Galesburg, Illinois, United States
Illinois CancerCare-Kewanee Clinic
🇺🇸
Kewanee, Illinois, United States
Illinois CancerCare-Macomb
🇺🇸
Macomb, Illinois, United States
Carle Physician Group-Mattoon/Charleston
🇺🇸
Mattoon, Illinois, United States
Cancer Care Center of O'Fallon
🇺🇸
O'Fallon, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸
Ottawa, Illinois, United States
Illinois CancerCare-Pekin
🇺🇸
Pekin, Illinois, United States
OSF Saint Francis Radiation Oncology at Pekin
🇺🇸
Pekin, Illinois, United States
Illinois CancerCare-Peoria
🇺🇸
Peoria, Illinois, United States
OSF Saint Francis Radiation Oncology at Peoria Cancer Center
🇺🇸
Peoria, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸
Peoria, Illinois, United States
OSF Saint Francis Medical Center
🇺🇸
Peoria, Illinois, United States
Illinois CancerCare-Peru
🇺🇸
Peru, Illinois, United States
Valley Radiation Oncology
🇺🇸
Peru, Illinois, United States
Illinois CancerCare-Princeton
🇺🇸
Princeton, Illinois, United States
Southern Illinois University School of Medicine
🇺🇸
Springfield, Illinois, United States
Springfield Clinic
🇺🇸
Springfield, Illinois, United States
Springfield Memorial Hospital
🇺🇸
Springfield, Illinois, United States
Southwest Illinois Health Services LLP
🇺🇸
Swansea, 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
Mary Greeley Medical Center
🇺🇸
Ames, Iowa, United States
McFarland Clinic - Ames
🇺🇸
Ames, Iowa, United States
McFarland Clinic - Boone
🇺🇸
Boone, Iowa, United States
Mercy Cancer Center-West Lakes
🇺🇸
Clive, Iowa, United States
UI Health Care Mission Cancer and Blood - West Des Moines Clinic
🇺🇸
Clive, Iowa, United States
Alegent Health Mercy Hospital
🇺🇸
Council Bluffs, Iowa, United States
Greater Regional Medical Center
🇺🇸
Creston, Iowa, United States
Mercy Medical Center - Des Moines
🇺🇸
Des Moines, Iowa, United States
UI Health Care Mission Cancer and Blood - Laurel Clinic
🇺🇸
Des Moines, Iowa, United States
McFarland Clinic - Trinity Cancer Center
🇺🇸
Fort Dodge, Iowa, United States
McFarland Clinic - Jefferson
🇺🇸
Jefferson, Iowa, United States
McFarland Clinic - Marshalltown
🇺🇸
Marshalltown, Iowa, United States
Mercy Medical Center-West Lakes
🇺🇸
West Des Moines, Iowa, United States
Lawrence Memorial Hospital
🇺🇸
Lawrence, 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
🇺🇸
Wichita, Kansas, United States
Flaget Memorial Hospital
🇺🇸
Bardstown, Kentucky, United States
Commonwealth Cancer Center-Corbin
🇺🇸
Corbin, Kentucky, United States
Saint Joseph Radiation Oncology Resource Center
🇺🇸
Lexington, Kentucky, United States
Saint Joseph Hospital East
🇺🇸
Lexington, Kentucky, United States
Saint Joseph London
🇺🇸
London, Kentucky, United States
Jewish Hospital
🇺🇸
Louisville, Kentucky, United States
Saints Mary and Elizabeth Hospital
🇺🇸
Louisville, Kentucky, United States
UofL Health Medical Center Northeast
🇺🇸
Louisville, Kentucky, United States
Jewish Hospital Medical Center South
🇺🇸
Shepherdsville, Kentucky, United States
Ochsner Medical Center Jefferson
🇺🇸
New Orleans, Louisiana, United States
Henry Ford Cancer Institute-Downriver
🇺🇸
Brownstown, Michigan, United States
Henry Ford Macomb Hospital-Clinton Township
🇺🇸
Clinton Township, Michigan, United States
Henry Ford Hospital
🇺🇸
Detroit, Michigan, United States
Allegiance Health
🇺🇸
Jackson, Michigan, United States
Henry Ford Macomb Health Center - Shelby Township
🇺🇸
Shelby, Michigan, United States
Henry Ford West Bloomfield Hospital
🇺🇸
West Bloomfield, Michigan, United States
Mayo Clinic in Rochester
🇺🇸
Rochester, Minnesota, United States
Parkland Health Center-Bonne Terre
🇺🇸
Bonne Terre, Missouri, United States
Mercy Cancer Center - Cape Girardeau
🇺🇸
Cape Girardeau, Missouri, United States
Saint Francis Medical Center
🇺🇸
Cape Girardeau, Missouri, United States
MU Health Care Goldschmidt Cancer Center
🇺🇸
Jefferson City, Missouri, United States
Missouri Baptist Medical Center
🇺🇸
Saint Louis, 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
Community Hospital of Anaconda
🇺🇸
Anaconda, Montana, United States
Billings Clinic Cancer Center
🇺🇸
Billings, Montana, United States
Bozeman Health Deaconess Hospital
🇺🇸
Bozeman, Montana, United States
Benefis Sletten Cancer Institute
🇺🇸
Great Falls, Montana, United States
Great Falls Clinic
🇺🇸
Great Falls, Montana, United States
Saint Peter's Community Hospital
🇺🇸
Helena, Montana, United States
Logan Health Medical Center
🇺🇸
Kalispell, Montana, United States
Community Medical Center
🇺🇸
Missoula, Montana, United States
Nebraska Cancer Specialists/Oncology Hematology West PC
🇺🇸
Grand Island, Nebraska, United States
Fred and Pamela Buffett Cancer Center - Kearney
🇺🇸
Kearney, Nebraska, United States
CHI Health Good Samaritan
🇺🇸
Kearney, Nebraska, United States
Saint Elizabeth Regional Medical Center
🇺🇸
Lincoln, Nebraska, United States
Alegent Health Immanuel Medical Center
🇺🇸
Omaha, Nebraska, United States
Hematology and Oncology Consultants PC
🇺🇸
Omaha, Nebraska, United States
Alegent Health Bergan Mercy Medical Center
🇺🇸
Omaha, Nebraska, United States
Alegent Health Lakeside Hospital
🇺🇸
Omaha, Nebraska, United States
Creighton University Medical Center
🇺🇸
Omaha, Nebraska, United States
Midlands Community Hospital
🇺🇸
Papillion, Nebraska, United States
Comprehensive Cancer Centers of Nevada - Henderson
🇺🇸
Henderson, Nevada, United States
OptumCare Cancer Care at Seven Hills
🇺🇸
Henderson, Nevada, United States
OptumCare Cancer Care at Charleston
🇺🇸
Las Vegas, Nevada, United States
Radiation Oncology Centers of Nevada Central
🇺🇸
Las Vegas, Nevada, United States
GenesisCare USA - Las Vegas
🇺🇸
Las Vegas, Nevada, United States
Radiation Oncology Centers of Nevada Southeast
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Northwest
🇺🇸
Las Vegas, Nevada, United States
OptumCare Cancer Care at MountainView
🇺🇸
Las Vegas, Nevada, United States
Alliance for Childhood Diseases/Cure 4 the Kids Foundation
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada-Summerlin
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada
🇺🇸
Las Vegas, Nevada, United States
OptumCare Cancer Care at Fort Apache
🇺🇸
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
Saint Mary's Regional Medical Center
🇺🇸
Reno, Nevada, United States
Radiation Oncology Associates
🇺🇸
Reno, Nevada, United States
Good Samaritan Hospital - Cincinnati
🇺🇸
Cincinnati, Ohio, United States
Bethesda North Hospital
🇺🇸
Cincinnati, Ohio, United States
TriHealth Cancer Institute-Westside
🇺🇸
Cincinnati, Ohio, United States
TriHealth Cancer Institute-Anderson
🇺🇸
Cincinnati, Ohio, United States
Cancer Centers of Southwest Oklahoma Research
🇺🇸
Lawton, Oklahoma, United States
University of Oklahoma Health Sciences Center
🇺🇸
Oklahoma City, Oklahoma, United States
University of Pittsburgh Cancer Institute (UPCI)
🇺🇸
Pittsburgh, Pennsylvania, United States
Medical University of South Carolina
🇺🇸
Charleston, South Carolina, United States
Memorial Hospital
🇺🇸
Chattanooga, Tennessee, United States
Pulmonary Medicine Center of Chattanooga-Hixson
🇺🇸
Hixson, Tennessee, United States
Memorial GYN Plus
🇺🇸
Ooltewah, Tennessee, United States
Saint Joseph Regional Cancer Center
🇺🇸
Bryan, Texas, United States
MD Anderson in The Woodlands
🇺🇸
Conroe, Texas, United States
UT Southwestern/Simmons Cancer Center-Dallas
🇺🇸
Dallas, Texas, United States
Lyndon Baines Johnson General Hospital
🇺🇸
Houston, Texas, United States
M D Anderson Cancer Center
🇺🇸
Houston, Texas, United States
MD Anderson West Houston
🇺🇸
Houston, Texas, United States
MD Anderson League City
🇺🇸
League City, Texas, United States
UT Southwestern Clinical Center at Richardson/Plano
🇺🇸
Richardson, Texas, United States
MD Anderson in Sugar Land
🇺🇸
Sugar Land, Texas, United States
University of Virginia Cancer Center
🇺🇸
Charlottesville, Virginia, United States
Overlake Medical Center
🇺🇸
Bellevue, Washington, United States
Highline Medical Center-Main Campus
🇺🇸
Burien, Washington, United States
Saint Elizabeth Hospital
🇺🇸
Enumclaw, Washington, United States
Saint Francis Hospital
🇺🇸
Federal Way, Washington, United States
Saint Clare Hospital
🇺🇸
Lakewood, Washington, United States
Harrison HealthPartners Hematology and Oncology-Poulsbo
🇺🇸
Poulsbo, Washington, United States
Valley Medical Center
🇺🇸
Renton, Washington, United States
Fred Hutchinson Cancer Center
🇺🇸
Seattle, Washington, United States
University of Washington Medical Center - Montlake
🇺🇸
Seattle, Washington, United States
Saint Michael Cancer Center
🇺🇸
Silverdale, Washington, 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