Maintenance Chemotherapy With or Without Local Consolidative Therapy in Treating Patients With Stage IV Non-small Cell Lung Cancer

Phase 2

Active, not recruiting

Conditions: Recurrent Non-Small Cell Lung Carcinoma
Stage IV Non-Small Cell Lung Cancer

Interventions: Drug: Docetaxel
Radiation: 3-Dimensional Conformal Radiation Therapy (3D-CRT)
Drug: Gemcitabine
Drug: Pemetrexed Disodium
Drug: Erlotinib Hydrochloride
Radiation: Intensity-Modulated Radiation Therapy (IMRT)
Drug: Pembrolizumab
Radiation: Stereotactic Body Radiation Therapy (SBRT)

Registration Number: NCT03137771

Lead Sponsor: NRG Oncology

Brief Summary: This randomized phase II/III trial studies how well giving maintenance chemotherapy with or without local consolidation therapy works in treating patients with stage IV non-small cell lung cancer. Drugs used in maintenance chemotherapy, such as docetaxel, pemetrexed disodium, erlotinib hydrochloride, and gemcitabine 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. Local consolidation therapy such as radiation/stereotactic body radiation or surgery may kill cancer cells left after initial treatment. Giving maintenance chemotherapy and local consolidation therapy together may work better than maintenance chemotherapy alone in treating patients with stage IV non-small cell lung cancer.

Detailed Description: PRIMARY OBJECTIVES:

Phase II

To evaluate the impact of adding local consolidative therapy (LCT) to maintenance systemic therapy versus maintenance systemic therapy alone on progression-free survival for patients with metastatic non-small cell lung cancer (NSCLC) with no evidence of progression and limited metastatic sites after first-line systemic therapy.

Phase III

To evaluate the impact of adding LCT to maintenance systemic therapy versus maintenance systemic therapy alone on overall survival for patients with metastatic NSCLC with no evidence of progression and limited metastatic sites after first-line systemic therapy.

SECONDARY OBJECTIVES:

I. To evaluate the impact of adding LCT to maintenance systemic therapy versus maintenance systemic therapy alone on in-field local failure.

II. To evaluate the impact of adding LCT to maintenance systemic therapy versus maintenance systemic therapy alone on the time to development of new lesions.

III. To evaluate the impact of adding LCT to maintenance systemic therapy versus maintenance systemic therapy alone on toxicity.

IV. To evaluate the impact of adding LCT to maintenance systemic therapy versus maintenance systemic therapy alone on duration of maintenance systemic therapy usage.

V. To evaluate the effect of adding LCT to systemic therapy in limited stage IV NSCLC on Quality of Life (QOL).

VI. To collect biospecimens and evaluate the correlation between clinical outcomes and circulating tumor DNA (ctDNA).

Patients are randomized 2:1 between the SBRT and chemotherapy vs. chemotherapy alone arms.

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

Recruitment & Eligibility

Status: ACTIVE_NOT_RECRUITING

Sex: All

Target Recruitment: 218

Inclusion Criteria

Patients must have the psychological ability and general health that permits completion of the study requirements and required follow up
Women of childbearing potential and men who are sexually active should be willing and able to use medically acceptable forms of contraception during the trial and for up to 180 days after completion of all treatment to prevent pregnancy or fathering a child.
Pathologically proven diagnosis of NSCLC, with metastases (stage IV disease) present prior to registration; this includes patients newly diagnosed with metastatic disease or those initially diagnosed and treated for stage I-III NSCLC who ultimately develop limited metastases. Limited metastases is defined as 3 or fewer sites of metastatic disease
Appropriate stage for study entry based on the following diagnostic workup:
- History/physical examination by a radiation oncologist (and a surgeon if surgery is planned) within 30 days prior to registration
- Imaging proof of limited metastatic disease and response to therapy/stable disease, by at least diagnostic quality CT chest through the adrenals or positron emission tomography (PET)/CT within 30 days prior to registration
Zubrod performance status 0, 1, or 2 within 30 days prior to registration
Adequate organ and hematologic/bone marrow function within 14 days prior to registration, defined as follows:
- Aspartate transaminase (AST) and alanine transaminase (ALT) ≤ 2.5 × upper limit of normal (ULN) or ≤ 5 × ULN with metastatic liver disease
- Total bilirubin ≤ 1.5 × ULN
- Absolute neutrophil count (ANC) ≥ 500 cells/mm3
- Platelets ≥ 50,000 cells/mm3
- Renal:
- Creatinine ≤ 1.5 x ULN; or
- Creatinine Clearance (CrCl) > 45 mL/min if creatinine > 1.5 x ULN (calculated CrCl based on Cockcroft-Gault equation)
HIV-infected patients on effective anti-retroviral therapy with undetectable viral load within 6 months are eligible for this trial.
For patients who will undergo resection of disease (if randomized to Arm 2 and dispositioned to receive surgery), adequate pre-surgical work-up for anticipated surgery, as defined by institutional guidelines.
Negative serum pregnancy test within one week prior to registration for females of childbearing potential
Patients must have received first-line/induction systemic therapy comprising of immunotherapy and/or platinum-based chemotherapy (at least 4 cycles or courses but less than 6, i.e. 4-5 cycles/courses), and achieved stable disease or a partial response. Though the intention is for every course/cycle to be identical in an induction regimen, Some but not all of the 4-5 cycles may omit an immunotherapy or platinum compound if the treating physician determines it is in the patient's best interest secondary to toxicity or other institutional parameter.
For patients treated with nivolumab, ipilimumab and 2 cycles of chemotherapy, the 4-5 cycles requirement will be met by 4-5 total doses of nivolumab.
For patients treated with nivolumab and ipilimumab, this requirement will be met by 2 doses of ipilimumab and 4-5 doses of nivolumab.
After induction systemic therapy, patients must have a minimum of one site of disease, primary or metastasis, present for potential consolidation with local therapy. All sites of disease present after induction systemic therapy, primary and metastases (up to 3) are able to be consolidated with local therapy;
Prior systemic therapy as part of concurrent treatment approach for previously diagnosed stage I-III NSCLC, adjuvant or neo-adjuvant therapy for stage I-III NSCLC, as adjuvant therapy for previously resected or irradiated NSCLC, or for other previous cancers is permitted
For de novo stage IV NSCLC patients (patients with metastatic disease at first presentation), primary disease must be treatable with local therapy in the form of SBRT or hypofractionated radiation. If the primary disease is found in the peripheral or central lung parenchyma without nodal disease, for instance, SBRT may be employed at the discretion of the treating institution. If primary disease is more advanced with involvement of the mediastinum (T4 tumor, N1-N3 disease, etc.), these volumes should be technically treatable with hypofractionated radiation; surgery should only be used for metastatic tumors that can be completely resected by lobectomy, segmentectomy, or wide wedge resection.
If primary disease in the thoracic cavity was previously treated with local therapy in the form of surgery or radiation, any new local/regional disease recurrence should be technically treatable with SBRT or hypofractionated radiation after induction systemic therapy.
The patient or a legally authorized representative must provide study-specific informed consent prior to registration.
Radiotherapy for patients with brain metastases prior to registration is acceptable.
Patients with brain metastases are eligible if these lesions have been previously treated or resolved and the patients have no clinical or radiographic evidence of progression prior to registration.
Subjects may receive palliative radiotherapy for symptomatic metastases or primary disease prior to registration provided that there is at least one other non-irradiated lesion amenable to LCT at the time of registration.

Exclusion Criteria

Clinical or radiologic evidence of untreated and/or progressive brain metastases prior to registration after induction systemic therapy
Cutaneous metastasis of NSCLC
Metastatic disease invading the esophagus, stomach, intestines, or mesenteric lymph nodes if not a candidate for surgery for these lesions
Prior invasive malignancy (except non-melanomatous skin cancer, low or intermediate risk prostate cancer, or in situ carcinoma of breast, oral cavity, skin, or cervix) unless disease free for a minimum of one year
Metastases located within 3 cm of previously irradiated (< 3 Gy per fraction) structures if if not a candidate for surgery for these lesions and if:
- Spinal cord previously irradiated to > 40 Gy
- Brachial plexus previously irradiated to > 50 Gy
- Small intestine, large intestine, or stomach previously irradiated to > 45 Gy
- Brainstem previously irradiated to > 50 Gy
- Lung previously irradiated with prior V20 Gy > 35%
Patients receiving targeted therapy (non-cytotoxic systemic therapy) for NSCLC in the first-line setting
Patients with NSCLC who have driver mutations for which targeted therapies (non-cytotoxic, non-immunotherapy based systemic therapy including but not limited to tyrosine-kinase inhibitors) are available. Such designations would include but not be limited to treatments targeting epidermal growth factor receptor (EGFR) mutant or anaplastic lymphoma kinase (ALK) positive NSCLC.
If a patient has progressed in previous areas of primary disease that received definitive doses of radiation, these patients would require re-irradiation in previous high dose anatomic areas and are not eligible for this study.
Patients with malignant pleural effusions that do not resolve after first-line systemic therapy; patients with pleural effusions that have become too small for thoracentesis at the time of registration would be permitted on study, indicating a significant response to first-line systemic therapy
Patients with more than 3 discrete locations of extra-cranial metastatic disease after first-line systemic therapy requiring more than 3 radiation/surgery plans to cover these distinct metastatic disease entities
Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration
Pregnancy or women of childbearing potential and men who are sexually active and not willing/able to use medically acceptable forms of contraception during treatment and for 180 days after the completion of all treatment. This exclusion is necessary because the treatment involved in this study may be significantly teratogenic. Women who are breastfeeding (and unwilling to discontinue) are also excluded
Participation in any investigational drug study for the treatment of cancer within 4 weeks prior to registration.
For patients who received immunotherapy during induction, patients on chronic steroids or who have active autoimmune disease for which they received systemic treatment in the previous 2 years with corticosteroids, disease modifying agents, or immunosuppressive drugs are not eligible. Replacement therapy (thyroxine, insulin or physiological corticosteroid replacement for adrenal or pituitary insufficiency) is allowed. Patients with active interstitial lung disease or who have a history of pneumonitis for which they had received glucocorticoids are not eligible
Use of bevacizumab or other antiangiogenic therapy in first-line or planned maintenance therapy (due to potential for increased complications from local therapy

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Arm 1 (systemic maintenance chemotherapy)	Docetaxel	Patients may receive docetaxel IV over 60 minutes on day 1, erlotinib hydrochloride by mouth daily, or gemcitabine IV over 30 minutes on days 1 and 8. Patients with non-squamous non-small cell lung cancer may receive pemetrexed disodium IV over 10 minutes on day 1 alone or in combination with pembrolizumab IV over 30 minutes. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.
Arm 1 (systemic maintenance chemotherapy)	Gemcitabine	Patients may receive docetaxel IV over 60 minutes on day 1, erlotinib hydrochloride by mouth daily, or gemcitabine IV over 30 minutes on days 1 and 8. Patients with non-squamous non-small cell lung cancer may receive pemetrexed disodium IV over 10 minutes on day 1 alone or in combination with pembrolizumab IV over 30 minutes. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.
Arm 1 (systemic maintenance chemotherapy)	Pemetrexed Disodium	Patients may receive docetaxel IV over 60 minutes on day 1, erlotinib hydrochloride by mouth daily, or gemcitabine IV over 30 minutes on days 1 and 8. Patients with non-squamous non-small cell lung cancer may receive pemetrexed disodium IV over 10 minutes on day 1 alone or in combination with pembrolizumab IV over 30 minutes. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.
Arm 1 (systemic maintenance chemotherapy)	Erlotinib Hydrochloride	Patients may receive docetaxel IV over 60 minutes on day 1, erlotinib hydrochloride by mouth daily, or gemcitabine IV over 30 minutes on days 1 and 8. Patients with non-squamous non-small cell lung cancer may receive pemetrexed disodium IV over 10 minutes on day 1 alone or in combination with pembrolizumab IV over 30 minutes. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.
Arm 2 (LCT + systemic maintenance chemotherapy)	3-Dimensional Conformal Radiation Therapy (3D-CRT)	Patients undergo local consolidative therapy (LCT) over 2-5 weeks, consisting of SBRT/hypofractionated radiation to the primary tumor and metastatic sites or surgery of metastatic sites. Hypofractionated radiation using IMRT or 3D-CRT can be given in place of SBRT. Within 2 weeks after completion of LCT (3 weeks if surgery occurred), patients receive chemotherapy as in Arm 1.
Arm 1 (systemic maintenance chemotherapy)	Pembrolizumab	Patients may receive docetaxel IV over 60 minutes on day 1, erlotinib hydrochloride by mouth daily, or gemcitabine IV over 30 minutes on days 1 and 8. Patients with non-squamous non-small cell lung cancer may receive pemetrexed disodium IV over 10 minutes on day 1 alone or in combination with pembrolizumab IV over 30 minutes. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.
Arm 2 (LCT + systemic maintenance chemotherapy)	Docetaxel	Patients undergo local consolidative therapy (LCT) over 2-5 weeks, consisting of SBRT/hypofractionated radiation to the primary tumor and metastatic sites or surgery of metastatic sites. Hypofractionated radiation using IMRT or 3D-CRT can be given in place of SBRT. Within 2 weeks after completion of LCT (3 weeks if surgery occurred), patients receive chemotherapy as in Arm 1.
Arm 2 (LCT + systemic maintenance chemotherapy)	Gemcitabine	Patients undergo local consolidative therapy (LCT) over 2-5 weeks, consisting of SBRT/hypofractionated radiation to the primary tumor and metastatic sites or surgery of metastatic sites. Hypofractionated radiation using IMRT or 3D-CRT can be given in place of SBRT. Within 2 weeks after completion of LCT (3 weeks if surgery occurred), patients receive chemotherapy as in Arm 1.
Arm 2 (LCT + systemic maintenance chemotherapy)	Intensity-Modulated Radiation Therapy (IMRT)	Patients undergo local consolidative therapy (LCT) over 2-5 weeks, consisting of SBRT/hypofractionated radiation to the primary tumor and metastatic sites or surgery of metastatic sites. Hypofractionated radiation using IMRT or 3D-CRT can be given in place of SBRT. Within 2 weeks after completion of LCT (3 weeks if surgery occurred), patients receive chemotherapy as in Arm 1.
Arm 2 (LCT + systemic maintenance chemotherapy)	Pemetrexed Disodium	Patients undergo local consolidative therapy (LCT) over 2-5 weeks, consisting of SBRT/hypofractionated radiation to the primary tumor and metastatic sites or surgery of metastatic sites. Hypofractionated radiation using IMRT or 3D-CRT can be given in place of SBRT. Within 2 weeks after completion of LCT (3 weeks if surgery occurred), patients receive chemotherapy as in Arm 1.
Arm 2 (LCT + systemic maintenance chemotherapy)	Stereotactic Body Radiation Therapy (SBRT)	Patients undergo local consolidative therapy (LCT) over 2-5 weeks, consisting of SBRT/hypofractionated radiation to the primary tumor and metastatic sites or surgery of metastatic sites. Hypofractionated radiation using IMRT or 3D-CRT can be given in place of SBRT. Within 2 weeks after completion of LCT (3 weeks if surgery occurred), patients receive chemotherapy as in Arm 1.
Arm 2 (LCT + systemic maintenance chemotherapy)	Erlotinib Hydrochloride	Patients undergo local consolidative therapy (LCT) over 2-5 weeks, consisting of SBRT/hypofractionated radiation to the primary tumor and metastatic sites or surgery of metastatic sites. Hypofractionated radiation using IMRT or 3D-CRT can be given in place of SBRT. Within 2 weeks after completion of LCT (3 weeks if surgery occurred), patients receive chemotherapy as in Arm 1.
Arm 2 (LCT + systemic maintenance chemotherapy)	Pembrolizumab	Patients undergo local consolidative therapy (LCT) over 2-5 weeks, consisting of SBRT/hypofractionated radiation to the primary tumor and metastatic sites or surgery of metastatic sites. Hypofractionated radiation using IMRT or 3D-CRT can be given in place of SBRT. Within 2 weeks after completion of LCT (3 weeks if surgery occurred), patients receive chemotherapy as in Arm 1.

Primary Outcome Measures

Name	Time	Method
[Phase II] Progression-free Survival	From randomization to first date of local or regional disease, distant metastases, second primary tumor, death, or last follow-up, whichever comes first. Maximum follow-up time at time of analysis was 5.4 years.	Progression-free survival (PFS) is estimated by the Kaplan-Meier method. Progression-free survival time is measured from randomization to the first date of local or regional disease, distant metastases, second primary tumor, death due to any cause, or last known follow-up (censored). Analysis was to occur after progression or death was reported for 138 participants.
[Phase III] Overall Survival	From randomization to death or last follow-up.	Overall survival is estimated by the Kaplan-Meier method. Survival time is measured from randomization to date of death from any cause or last known follow-up (censored). Analysis was to occur after \\\\ deaths were reported.

Secondary Outcome Measures

Name	Time	Method
In-Field Local Failure	From randomization to first in-field failure, death or last follow-up, whichever occurs first. Maximum follow-up at time of analysis was 5.4 years. The one- and two-year estimates are reported.	In-field local failure is defined as local or marginal failure. In-field local failure rates are estimated by the cumulative incidence method, in which death without failure is treated as competing risk and participants alive without failure are censored at last known follow-up. Analysis was to occur after progression or death was reported for 138 participants.
Development of New Lesions	From randomization to the first occurrence of any new lesions, death, or last follow-up, whichever occurs first. Maximum follow-up time at the time of analysis was 5.4 years. One- and two-year estimates are reported.	New lesion rates are estimated by the cumulative incidence method, in which death without new lesions is treated as competing risk and participants alive without new lesions are censored at last known follow-up. Analysis was to occur after progression or death was reported for 138 participants.
Number of Participants by Highest Grade Adverse Event Reported	From randomization to last follow-up. Maximum follow-up at time of analysis was 5.4 years.	National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 grades adverse event severity as follows: 1 = mild, 2 = moderate, 3 = severe, 4 = life-threatening, 5 = death related to adverse event. Summary data is provided in this outcome measure; see Adverse Events Module for specific adverse event data.
Duration of Maintenance Chemotherapy Usage	Up to 3 years	Will be performed on an intent to treat basis.

Trial Locations

Locations (301): Arizona Center for Cancer Care - Gilbert
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Gilbert, Arizona, United States
Arizona Center for Cancer Care - Scottsdale
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Scottsdale, Arizona, United States
Los Angeles General Medical Center
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Los Angeles, California, United States
UW Health Carbone Cancer Center Rockford
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Rockford, Illinois, United States
Springfield Memorial Hospital
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Springfield, Illinois, United States
Our Lady of the Lake Physician Group
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Baton Rouge, Louisiana, United States
Henry Ford Health Saint John Hospital
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Detroit, Michigan, United States
University of Michigan Health - Sparrow Lansing
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Lansing, Michigan, United States
Michigan Healthcare Professionals Pontiac
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Pontiac, Michigan, United States
Corewell Health William Beaumont University Hospital
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Royal Oak, Michigan, United States
MyMichigan Medical Center Saginaw
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Saginaw, Michigan, United States
Corewell Health Beaumont Troy Hospital
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Troy, Michigan, United States
Henry Ford Health Warren Hospital
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Warren, Michigan, United States
Bozeman Health Deaconess Hospital
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Bozeman, Montana, United States
Benefis Sletten Cancer Institute
🇺🇸
Great Falls, Montana, United States
Logan Health Medical Center
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Kalispell, Montana, United States
Dartmouth Cancer Center - North
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Saint Johnsbury, Vermont, United States
Marshfield Medical Center - Minocqua
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Minocqua, Wisconsin, United States
University of Alabama at Birmingham Cancer Center
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Birmingham, Alabama, United States
Arizona Center for Cancer Care-Peoria
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Peoria, Arizona, United States
Mayo Clinic Hospital in Arizona
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Phoenix, Arizona, 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
University of Arkansas for Medical Sciences
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Little Rock, Arkansas, United States
Alta Bates Summit Medical Center-Herrick Campus
🇺🇸
Berkeley, California, United States
City of Hope Comprehensive Cancer Center
🇺🇸
Duarte, California, United States
UC San Diego Moores Cancer Center
🇺🇸
La Jolla, California, United States
USC / Norris Comprehensive Cancer Center
🇺🇸
Los Angeles, California, United States
Memorial Medical Center
🇺🇸
Modesto, California, United States
Saint Joseph Hospital - Orange
🇺🇸
Orange, California, United States
The Permanente Medical Group-Roseville Radiation Oncology
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Roseville, California, United States
Sutter Medical Center Sacramento
🇺🇸
Sacramento, California, United States
University of California Davis Comprehensive Cancer Center
🇺🇸
Sacramento, California, United States
Saint Helena Hospital
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Saint Helena, California, United States
Salinas Valley Memorial
🇺🇸
Salinas, California, United States
City of Hope South Pasadena
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South Pasadena, California, United States
Kaiser Permanente Cancer Treatment Center
🇺🇸
South San Francisco, California, United States
Gene Upshaw Memorial Tahoe Forest Cancer Center
🇺🇸
Truckee, California, United States
Penrose-Saint Francis Healthcare
🇺🇸
Colorado Springs, Colorado, United States
UCHealth Memorial Hospital Central
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Colorado Springs, Colorado, United States
Porter Adventist Hospital
🇺🇸
Denver, Colorado, United States
Poudre Valley Hospital
🇺🇸
Fort Collins, Colorado, United States
Yale University
🇺🇸
New Haven, Connecticut, United States
Helen F Graham Cancer Center
🇺🇸
Newark, Delaware, United States
Beebe Health Campus
🇺🇸
Rehoboth Beach, Delaware, United States
UM Sylvester Comprehensive Cancer Center at Coral Gables
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Coral Gables, Florida, United States
UM Sylvester Comprehensive Cancer Center at Deerfield Beach
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Deerfield Beach, Florida, United States
University of Florida Health Science Center - Gainesville
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Gainesville, Florida, United States
Mayo Clinic in Florida
🇺🇸
Jacksonville, Florida, United States
University of Miami Miller School of Medicine-Sylvester Cancer Center
🇺🇸
Miami, Florida, United States
Miami Cancer Institute
🇺🇸
Miami, Florida, United States
UM Sylvester Comprehensive Cancer Center at Kendall
🇺🇸
Miami, Florida, United States
Orlando Health Cancer Institute
🇺🇸
Orlando, Florida, United States
UM Sylvester Comprehensive Cancer Center at Plantation
🇺🇸
Plantation, Florida, United States
Tallahassee Memorial HealthCare
🇺🇸
Tallahassee, Florida, United States
Moffitt Cancer Center
🇺🇸
Tampa, Florida, United States
Cleveland Clinic-Weston
🇺🇸
Weston, Florida, United States
Grady Health System
🇺🇸
Atlanta, Georgia, United States
Emory University Hospital Midtown
🇺🇸
Atlanta, Georgia, United States
Emory University Hospital/Winship Cancer Institute
🇺🇸
Atlanta, Georgia, United States
Emory Saint Joseph's Hospital
🇺🇸
Atlanta, Georgia, United States
Augusta University Medical Center
🇺🇸
Augusta, Georgia, United States
Lewis Cancer and Research Pavilion at Saint Joseph's/Candler
🇺🇸
Savannah, Georgia, United States
Queen's Medical Center
🇺🇸
Honolulu, Hawaii, United States
The Cancer Center of Hawaii-Liliha
🇺🇸
Honolulu, Hawaii, United States
Saint Alphonsus Cancer Care Center-Nampa
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Nampa, Idaho, United States
Northwestern University
🇺🇸
Chicago, Illinois, United States
Rush University Medical Center
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Chicago, Illinois, United States
University of Illinois
🇺🇸
Chicago, Illinois, United States
Decatur Memorial Hospital
🇺🇸
Decatur, Illinois, United States
Crossroads Cancer Center
🇺🇸
Effingham, Illinois, United States
Western Illinois Cancer Treatment Center
🇺🇸
Galesburg, Illinois, United States
Edward Hines Jr VA Hospital
🇺🇸
Hines, Illinois, United States
Condell Memorial Hospital
🇺🇸
Libertyville, Illinois, United States
Loyola University Medical Center
🇺🇸
Maywood, Illinois, United States
Advocate Lutheran General Hospital
🇺🇸
Park Ridge, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸
Peoria, Illinois, United States
OSF Saint Francis Medical Center
🇺🇸
Peoria, Illinois, United States
Southwest Illinois Health Services LLP
🇺🇸
Swansea, Illinois, United States
Carle Cancer Center
🇺🇸
Urbana, Illinois, United States
Parkview Hospital Randallia
🇺🇸
Fort Wayne, Indiana, United States
Parkview Regional Medical Center
🇺🇸
Fort Wayne, Indiana, United States
Goshen Center for Cancer Care
🇺🇸
Goshen, Indiana, United States
Community Cancer Center East
🇺🇸
Indianapolis, Indiana, United States
Community Cancer Center South
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Indianapolis, Indiana, United States
Franciscan Health Indianapolis
🇺🇸
Indianapolis, Indiana, United States
Community Cancer Center North
🇺🇸
Indianapolis, Indiana, United States
Franciscan Health Mooresville
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Mooresville, Indiana, United States
Mercy Cancer Center-West Lakes
🇺🇸
Clive, Iowa, United States
Iowa Methodist Medical Center
🇺🇸
Des Moines, Iowa, United States
Mercy Medical Center - Des Moines
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Des Moines, Iowa, United States
University of Kansas Cancer Center
🇺🇸
Kansas City, Kansas, United States
Lawrence Memorial Hospital
🇺🇸
Lawrence, Kansas, United States
University of Kansas Cancer Center-Overland Park
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Overland Park, Kansas, United States
Ascension Via Christi Hospitals Wichita
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Wichita, Kansas, United States
Saint Elizabeth Healthcare Edgewood
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Edgewood, Kentucky, United States
University of Kentucky/Markey Cancer Center
🇺🇸
Lexington, Kentucky, United States
Norton Hospital Pavilion and Medical Campus
🇺🇸
Louisville, Kentucky, United States
The James Graham Brown Cancer Center at University of Louisville
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Louisville, Kentucky, United States
Norton Brownsboro Hospital and Medical Campus
🇺🇸
Louisville, Kentucky, United States
LSU Health Baton Rouge-North Clinic
🇺🇸
Baton Rouge, Louisiana, United States
Louisiana Hematology Oncology Associates LLC
🇺🇸
Baton Rouge, Louisiana, United States
Mary Bird Perkins Cancer Center
🇺🇸
Baton Rouge, Louisiana, United States
University of Maryland/Greenebaum Cancer Center
🇺🇸
Baltimore, Maryland, United States
Central Maryland Radiation Oncology in Howard County
🇺🇸
Columbia, Maryland, United States
UM Baltimore Washington Medical Center/Tate Cancer Center
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Glen Burnie, Maryland, United States
TidalHealth Richard A Henson Cancer Institute
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Ocean Pines, Maryland, United States
TidalHealth Peninsula Regional
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Salisbury, Maryland, United States
Massachusetts General Hospital Cancer Center
🇺🇸
Boston, Massachusetts, United States
Brigham and Women's Hospital
🇺🇸
Boston, Massachusetts, United States
Boston Medical Center
🇺🇸
Boston, Massachusetts, United States
Lahey Hospital and Medical Center
🇺🇸
Burlington, Massachusetts, United States
McLaren Cancer Institute-Bay City
🇺🇸
Bay City, Michigan, United States
McLaren Cancer Institute-Clarkston
🇺🇸
Clarkston, Michigan, United States
Henry Ford Macomb Hospital-Clinton Township
🇺🇸
Clinton Township, Michigan, United States
Wayne State University/Karmanos Cancer Institute
🇺🇸
Detroit, Michigan, United States
Henry Ford Hospital
🇺🇸
Detroit, Michigan, United States
Weisberg Cancer Treatment Center
🇺🇸
Farmington Hills, Michigan, United States
McLaren Cancer Institute-Flint
🇺🇸
Flint, Michigan, United States
Singh and Arora Hematology Oncology PC
🇺🇸
Flint, Michigan, United States
Allegiance Health
🇺🇸
Jackson, Michigan, United States
West Michigan Cancer Center
🇺🇸
Kalamazoo, Michigan, United States
Karmanos Cancer Institute at McLaren Greater Lansing
🇺🇸
Lansing, Michigan, United States
Mid-Michigan Physicians-Lansing
🇺🇸
Lansing, Michigan, United States
McLaren Cancer Institute-Lapeer Region
🇺🇸
Lapeer, Michigan, United States
Trinity Health Saint Mary Mercy Livonia Hospital
🇺🇸
Livonia, Michigan, United States
McLaren Cancer Institute-Macomb
🇺🇸
Mount Clemens, Michigan, United States
McLaren Cancer Institute-Northern Michigan
🇺🇸
Petoskey, Michigan, United States
McLaren-Port Huron
🇺🇸
Port Huron, Michigan, United States
University of Michigan Health - West
🇺🇸
Wyoming, Michigan, United States
Sanford Joe Lueken Cancer Center
🇺🇸
Bemidji, Minnesota, United States
Saint Luke's Hospital of Duluth
🇺🇸
Duluth, Minnesota, United States
Hennepin County Medical Center
🇺🇸
Minneapolis, Minnesota, United States
Coborn Cancer Center at Saint Cloud Hospital
🇺🇸
Saint Cloud, Minnesota, United States
Regions Hospital
🇺🇸
Saint Paul, Minnesota, United States
Saint Francis Medical Center
🇺🇸
Cape Girardeau, Missouri, United States
Siteman Cancer Center at West County Hospital
🇺🇸
Creve Coeur, Missouri, United States
Kansas City Veterans Affairs Medical Center
🇺🇸
Kansas City, Missouri, United States
Delbert Day Cancer Institute at PCRMC
🇺🇸
Rolla, Missouri, United States
Washington University School of Medicine
🇺🇸
Saint Louis, Missouri, United States
Missouri Baptist Medical Center
🇺🇸
Saint Louis, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸
Saint Louis, Missouri, United States
Mercy Hospital Springfield
🇺🇸
Springfield, Missouri, United States
Saint James Community Hospital and Cancer Treatment Center
🇺🇸
Butte, Montana, United States
Nebraska Methodist Hospital
🇺🇸
Omaha, Nebraska, United States
Alegent Health Bergan Mercy Medical Center
🇺🇸
Omaha, Nebraska, United States
Renown Regional Medical Center
🇺🇸
Reno, Nevada, United States
Wentworth-Douglass Hospital
🇺🇸
Dover, New Hampshire, United States
Dartmouth Hitchcock Medical Center/Dartmouth Cancer Center
🇺🇸
Lebanon, New Hampshire, United States
Memorial Sloan Kettering Basking Ridge
🇺🇸
Basking Ridge, New Jersey, United States
Memorial Sloan Kettering Monmouth
🇺🇸
Middletown, New Jersey, United States
Memorial Sloan Kettering Bergen
🇺🇸
Montvale, New Jersey, United States
Virtua Samson Cancer Center
🇺🇸
Moorestown, New Jersey, United States
Virtua Memorial
🇺🇸
Mount Holly, New Jersey, United States
Community Medical Center
🇺🇸
Toms River, New Jersey, United States
Virtua Voorhees
🇺🇸
Voorhees, New Jersey, United States
Lovelace Medical Center-Saint Joseph Square
🇺🇸
Albuquerque, New Mexico, United States
University of New Mexico Cancer Center
🇺🇸
Albuquerque, New Mexico, United States
Lovelace Radiation Oncology
🇺🇸
Albuquerque, New Mexico, United States
Christus Saint Vincent Regional Cancer Center
🇺🇸
Santa Fe, New Mexico, United States
Montefiore Medical Center-Einstein Campus
🇺🇸
Bronx, New York, United States
Montefiore Medical Center - Moses Campus
🇺🇸
Bronx, New York, United States
New York-Presbyterian/Brooklyn Methodist Hospital
🇺🇸
Brooklyn, New York, United States
Memorial Sloan Kettering Commack
🇺🇸
Commack, New York, United States
Memorial Sloan Kettering Westchester
🇺🇸
Harrison, New York, United States
Mount Sinai West
🇺🇸
New York, New York, United States
Mount Sinai Hospital
🇺🇸
New York, New York, United States
Memorial Sloan Kettering Cancer Center
🇺🇸
New York, New York, United States
University of Rochester
🇺🇸
Rochester, New York, United States
Stony Brook University Medical Center
🇺🇸
Stony Brook, New York, United States
State University of New York Upstate Medical University
🇺🇸
Syracuse, New York, United States
Memorial Sloan Kettering Nassau
🇺🇸
Uniondale, New York, United States
Dickstein Cancer Treatment Center
🇺🇸
White Plains, New York, United States
Carolinas Medical Center/Levine Cancer Institute
🇺🇸
Charlotte, North Carolina, United States
Atrium Health Pineville/LCI-Pineville
🇺🇸
Charlotte, North Carolina, United States
Atrium Health University City/LCI-University
🇺🇸
Charlotte, North Carolina, United States
Atrium Health Cabarrus/LCI-Concord
🇺🇸
Concord, North Carolina, United States
Duke University Medical Center
🇺🇸
Durham, North Carolina, United States
Atrium Health Union/LCI-Union
🇺🇸
Monroe, North Carolina, United States
CarolinaEast Medical Center
🇺🇸
New Bern, North Carolina, United States
Novant Cancer Institute Radiation Oncology - Supply
🇺🇸
Supply, North Carolina, United States
Novant Health Cancer Institute Radiation Oncology - Wilmington
🇺🇸
Wilmington, North Carolina, United States
Novant Health New Hanover Regional Medical Center
🇺🇸
Wilmington, North Carolina, United States
Sanford Bismarck Medical Center
🇺🇸
Bismarck, North Dakota, United States
Sanford Roger Maris Cancer Center
🇺🇸
Fargo, North Dakota, United States
Altru Cancer Center
🇺🇸
Grand Forks, North Dakota, United States
Cleveland Clinic Akron General
🇺🇸
Akron, Ohio, United States
UHHS-Chagrin Highlands Medical Center
🇺🇸
Beachwood, Ohio, United States
Geauga Hospital
🇺🇸
Chardon, Ohio, United States
Adena Regional Medical Center
🇺🇸
Chillicothe, Ohio, United States
University of Cincinnati Cancer Center-UC Medical Center
🇺🇸
Cincinnati, Ohio, United States
Case Western Reserve University
🇺🇸
Cleveland, Ohio, United States
Cleveland Clinic Cancer Center/Fairview Hospital
🇺🇸
Cleveland, Ohio, United States
Cleveland Clinic Foundation
🇺🇸
Cleveland, Ohio, United States
Ohio State University Comprehensive Cancer Center
🇺🇸
Columbus, Ohio, United States
The Mark H Zangmeister Center
🇺🇸
Columbus, Ohio, United States
Cleveland Clinic Cancer Center Mansfield
🇺🇸
Mansfield, Ohio, United States
Hillcrest Hospital Cancer Center
🇺🇸
Mayfield Heights, Ohio, United States
UH Seidman Cancer Center at Lake Health Mentor Campus
🇺🇸
Mentor, Ohio, United States
UH Seidman Cancer Center at Southwest General Hospital
🇺🇸
Middleburg Heights, Ohio, United States
University Hospitals Parma Medical Center
🇺🇸
Parma, Ohio, United States
University Hospitals Portage Medical Center
🇺🇸
Ravenna, Ohio, United States
North Coast Cancer Care
🇺🇸
Sandusky, Ohio, United States
UH Seidman Cancer Center at Firelands Regional Medical Center
🇺🇸
Sandusky, Ohio, United States
ProMedica Flower Hospital
🇺🇸
Sylvania, Ohio, United States
University of Cincinnati Cancer Center-West Chester
🇺🇸
West Chester, Ohio, United States
UH Seidman Cancer Center at Saint John Medical Center
🇺🇸
Westlake, Ohio, United States
UHHS-Westlake Medical Center
🇺🇸
Westlake, Ohio, United States
Cleveland Clinic Wooster Family Health and Surgery Center
🇺🇸
Wooster, Ohio, United States
Genesis Healthcare System Cancer Care Center
🇺🇸
Zanesville, Ohio, United States
University of Oklahoma Health Sciences Center
🇺🇸
Oklahoma City, Oklahoma, United States
Mercy Hospital Oklahoma City
🇺🇸
Oklahoma City, Oklahoma, United States
Good Samaritan Hospital
🇺🇸
Corvallis, Oregon, United States
Legacy Mount Hood Medical Center
🇺🇸
Gresham, Oregon, United States
Legacy Good Samaritan Hospital and Medical Center
🇺🇸
Portland, Oregon, United States
Providence Portland Medical Center
🇺🇸
Portland, Oregon, United States
Providence Saint Vincent Medical Center
🇺🇸
Portland, Oregon, United States
Bryn Mawr Hospital
🇺🇸
Bryn Mawr, Pennsylvania, United States
Geisinger Medical Center
🇺🇸
Danville, Pennsylvania, United States
Delaware County Memorial Hospital
🇺🇸
Drexel Hill, Pennsylvania, United States
Northeast Radiation Oncology Center
🇺🇸
Dunmore, Pennsylvania, United States
Saint Vincent Hospital
🇺🇸
Erie, Pennsylvania, United States
UPMC Pinnacle Cancer Center/Community Osteopathic Campus
🇺🇸
Harrisburg, Pennsylvania, United States
Penn State Milton S Hershey Medical Center
🇺🇸
Hershey, Pennsylvania, United States
Lancaster General Ann B Barshinger Cancer Institute
🇺🇸
Lancaster, Pennsylvania, United States
Lancaster General Hospital
🇺🇸
Lancaster, Pennsylvania, United States
Geisinger Medical Oncology-Lewisburg
🇺🇸
Lewisburg, Pennsylvania, United States
Lewistown Hospital
🇺🇸
Lewistown, Pennsylvania, United States
Paoli Memorial Hospital
🇺🇸
Paoli, Pennsylvania, United States
Thomas Jefferson University Hospital
🇺🇸
Philadelphia, Pennsylvania, United States
Fox Chase Cancer Center
🇺🇸
Philadelphia, Pennsylvania, United States
Jefferson Torresdale Hospital
🇺🇸
Philadelphia, Pennsylvania, United States
Geisinger Cancer Services-Pottsville
🇺🇸
Pottsville, Pennsylvania, United States
Guthrie Medical Group PC-Robert Packer Hospital
🇺🇸
Sayre, Pennsylvania, United States
Reading Hospital
🇺🇸
West Reading, Pennsylvania, United States
Geisinger Wyoming Valley/Henry Cancer Center
🇺🇸
Wilkes-Barre, Pennsylvania, United States
Asplundh Cancer Pavilion
🇺🇸
Willow Grove, Pennsylvania, United States
Lankenau Medical Center
🇺🇸
Wynnewood, Pennsylvania, United States
Prisma Health Cancer Institute - Spartanburg
🇺🇸
Boiling Springs, South Carolina, United States
Prisma Health Cancer Institute - Faris
🇺🇸
Greenville, South Carolina, United States
Saint Francis Cancer Center
🇺🇸
Greenville, South Carolina, United States
Prisma Health Cancer Institute - Eastside
🇺🇸
Greenville, South Carolina, United States
Self Regional Healthcare
🇺🇸
Greenwood, South Carolina, United States
Prisma Health Cancer Institute - Greer
🇺🇸
Greer, South Carolina, United States
Gibbs Cancer Center-Pelham
🇺🇸
Greer, South Carolina, United States
The Radiation Oncology Center-Hilton Head/Bluffton
🇺🇸
Hilton Head Island, South Carolina, United States
Prisma Health Cancer Institute - Seneca
🇺🇸
Seneca, South Carolina, United States
Spartanburg Medical Center
🇺🇸
Spartanburg, South Carolina, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸
Sioux Falls, South Dakota, United States
Baptist Memorial Hospital and Cancer Center-Memphis
🇺🇸
Memphis, Tennessee, United States
UT Southwestern/Simmons Cancer Center-Dallas
🇺🇸
Dallas, Texas, United States
UT Southwestern/Simmons Cancer Center-Fort Worth
🇺🇸
Fort Worth, Texas, United States
University of Texas Medical Branch
🇺🇸
Galveston, Texas, United States
M D Anderson Cancer Center
🇺🇸
Houston, Texas, United States
Covenant Medical Center-Lakeside
🇺🇸
Lubbock, Texas, United States
University of Texas Health Science Center at San Antonio
🇺🇸
San Antonio, Texas, United States
Huntsman Cancer Institute/University of Utah
🇺🇸
Salt Lake City, Utah, United States
George E Wahlen Department of Veterans Affairs Medical Center
🇺🇸
Salt Lake City, Utah, United States
VCU Massey Cancer Center at Stony Point
🇺🇸
Richmond, Virginia, United States
Virginia Commonwealth University/Massey Cancer Center
🇺🇸
Richmond, Virginia, United States
Legacy Salmon Creek Hospital
🇺🇸
Vancouver, Washington, United States
West Virginia University Healthcare
🇺🇸
Morgantown, West Virginia, United States
Langlade Hospital and Cancer Center
🇺🇸
Antigo, Wisconsin, United States
Ascension Saint Elizabeth Hospital
🇺🇸
Appleton, Wisconsin, United States
Aurora Cancer Care-Southern Lakes VLCC
🇺🇸
Burlington, 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
Saint Vincent Hospital Cancer Center Green Bay
🇺🇸
Green Bay, Wisconsin, United States
Saint Vincent Hospital Cancer Center at Saint Mary's
🇺🇸
Green Bay, Wisconsin, United States
Aurora BayCare Medical Center
🇺🇸
Green Bay, Wisconsin, United States
Aurora Cancer Care-Kenosha South
🇺🇸
Kenosha, Wisconsin, United States
Gundersen Lutheran Medical Center
🇺🇸
La Crosse, Wisconsin, United States
Aurora Bay Area Medical Group-Marinette
🇺🇸
Marinette, Wisconsin, United States
Marshfield Medical Center-Marshfield
🇺🇸
Marshfield, Wisconsin, United States
Froedtert Menomonee Falls Hospital
🇺🇸
Menomonee Falls, Wisconsin, United States
Aurora Cancer Care-Milwaukee
🇺🇸
Milwaukee, Wisconsin, United States
Aurora Saint Luke's Medical Center
🇺🇸
Milwaukee, Wisconsin, United States
Medical College of Wisconsin
🇺🇸
Milwaukee, Wisconsin, United States
Aurora Sinai Medical Center
🇺🇸
Milwaukee, Wisconsin, United States
Ascension Mercy Hospital
🇺🇸
Oshkosh, Wisconsin, United States
Vince Lombardi Cancer Clinic - Oshkosh
🇺🇸
Oshkosh, Wisconsin, United States
Aurora Cancer Care-Racine
🇺🇸
Racine, 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
Aspirus Regional Cancer Center
🇺🇸
Wausau, Wisconsin, United States
Aurora Cancer Care-Milwaukee West
🇺🇸
Wauwatosa, Wisconsin, United States
Aurora West Allis Medical Center
🇺🇸
West Allis, Wisconsin, United States
Froedtert West Bend Hospital/Kraemer Cancer Center
🇺🇸
West Bend, Wisconsin, United States
Marshfield Medical Center - Weston
🇺🇸
Weston, Wisconsin, United States
Aspirus Cancer Care - Wisconsin Rapids
🇺🇸
Wisconsin Rapids, Wisconsin, United States
Cross Cancer Institute
🇨🇦
Edmonton, Alberta, Canada
London Regional Cancer Program
🇨🇦
London, Ontario, Canada
Ottawa Hospital and Cancer Center-General Campus
🇨🇦
Ottawa, Ontario, Canada
Chaim Sheba Medical Center
🇮🇱
Tel Hashomer, Israel
King Faisal Specialist Hospital and Research Centre
🇸🇦
Riyadh, Saudi Arabia