Sorafenib Tosylate and Temsirolimus in Treating Patients With Recurrent Glioblastoma
- Conditions
- Adult GliosarcomaRecurrent Adult Brain NeoplasmAdult Glioblastoma
- Interventions
- Other: Laboratory Biomarker AnalysisProcedure: Conventional Surgery
- Registration Number
- NCT00329719
- Lead Sponsor
- National Cancer Institute (NCI)
- Brief Summary
This phase I/II trial studies the side effects and best dose of temsirolimus when given together with sorafenib tosylate and to see how well they work in treating patients with glioblastoma that has come back. Sorafenib tosylate may stop the growth of tumor cells by blocking blood flow to the tumor. Drugs used in chemotherapy, such as temsirolimus, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Sorafenib tosylate and temsirolimus may also stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Giving sorafenib tosylate with temsirolimus may kill more tumor cells.
- Detailed Description
Primary Objective -
Phase I (closed to accrual as of 01/11/2008):
To establish a maximum tolerable dose of temsirolimus in combination with sorafenib in patients with recurrent glioblastoma not receiving enzyme-inducing anticonvulsants (EIACs).
Phase II (closed to accrual as of 12/07/2012):
To assess the efficacy of temsirolimus and sorafenib in the treatment of recurrent glioblastoma in non-EIAC patients as measured by progression-free survival status at six months (PFS6).
Secondary Objectives -
Phase I (closed to accrual as of 01/11/2008):
I. To define the safety profile of temsirolimus and sorafenib in non-EIAC patients.
II. To assess the evidence of antitumor activity.
Phase II (closed to accrual as of 12/07/2012):
I. To assess the safety and toxicities of temsirolimus and sorafenib in the above-noted patient populations.
Outline: This is a multicenter, phase I, dose-escalation study followed by a phase II study.
Phase I (Arm A): Patients receive sorafenib orally (PO) twice daily (BID) on days 1-28 and temsirolimus intravenously (IV) over 30 minutes on days 1, 8, 15, and 22. Treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity. Cohorts of 3-6 patients receive escalating doses of temsirolimus until the maximum tolerated dose (MTD) is determined. The MTD is defined as the dose preceding that at which 2 of 3 or 2 of 6 patients experience dose-limiting toxicity.
Phase II: Patients are assigned to 1 of 3 treatment groups.
Group 1 (Arm B): Patients receive sorafenib and temsirolimus as in phase I at the MTD. (patients not undergoing surgery)
Group 2 (Arm C): Patients receive sorafenib PO BID on days 1-8 (15 doses) and temsirolimus IV at the MTD on day 1. Patients undergo surgery on day 8. (patients undergoing surgery) After recovering from surgery, patients receive sorafenib and temsirolimus as in phase I at the MTD.
Group 3 (Arm D): Patient receive sorafenib and temsirolimus as in phase I at the MTD. (patients who have received prior anti-vascular endothelial growth factor \[VEGF\] therapy and are not undergoing surgery)
Biopsy or resected tissue and blood are collected prior to treatment (usually at diagnosis) and analyzed for biomarkers. After completion of study treatment, patients are followed every 6 months for 5 years and then annually thereafter.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 115
- Central pathology review submission; this review is mandatory prior to registration to confirm eligibility; it should be initiated as soon after surgery as possible
- =< 2 prior systemic chemotherapy regimens
- Histological confirmation of a grade 4 astrocytoma (glioblastoma) or gliosarcoma, at primary diagnosis or recurrence by World Health Organization (WHO) criteria; central pathology review is mandatory prior to study entry to confirm eligibility
- Evidence of tumor progression by magnetic resonance imaging (MRI) or computed tomography (CT) scan following radiation therapy (RT) or following the most recent anti-tumor therapy
- Bidimensionally measurable or evaluable disease by MRI or CT scan
- Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0, 1, or 2
- >= 12 weeks since the completion of RT
- Fixed or decreasing dose of corticosteroids (or no corticosteroids) >= 1 week prior to registration
- >= 1 week from minor surgery other than venous line placement and > 3 weeks from major surgery (except for patients undergoing tumor tissue acquisition)
- >= 4 weeks since prior cytotoxic chemotherapy (>= 6 weeks for nitrosoureas)
- >= 2 weeks from cytostatic chemotherapy such as tamoxifen, cis-retinoic acid, or thalidomide (address questions regarding such agents to study chair)
- White blood cells (WBC) >= 3,000/mm^3
- Absolute neutrophil count (ANC) >= 1,500/mm^3
- Platelet count >= 100,000/mm^3
- Hemoglobin (Hgb) >= 10 gm/dL
- Total bilirubin =< 1.5 x upper limit of normal (ULN)
- Serum glutamic oxaloacetic transaminase (SGOT) (aspartate aminotransferase [AST]) =< 2.5 x ULN
- Creatinine =< 2.0 x ULN
- Serum cholesterol =< 350 mg/dL
- Serum triglycerides =< 400 mg/dL
- Willingness to provide the biologic specimens as required by the protocol; (please note that the willingness to participate pertains only to the patient and does not factor in the institution?s ability to participate in any part of the translational component)
-
Prior intratumoral chemotherapy (e.g., Gliadel or IL13-PE38QQR), stereotactic radiosurgery, or interstitial brachytherapy unless there is a separate lesion on MRI which is not part of the previous treatment field or there is proof of recurrent disease based on biopsy, MRI spectroscopy, or positron emission tomography (PET) scan
-
Prior CCI-779, sorafenib, or other agents specifically targeting mammalian target of rapamycin (mTOR) or raf; patients receiving prior agents inhibiting VEGF or VEGF receptor (R) (prior anti-VEGF group) are eligible but: 1) must be at least four weeks from last treatment with the agent(s); and 2) must have recovered from any clinically relevant toxicities attributable to this agent(s)
-
Evidence of bleeding diathesis or coagulopathy
- Note: Patients on prophylactic anticoagulation therapy (e.g., low-dose warfarin) are eligible provided their coagulation parameter levels are as follows: prothrombin time (International Normalized Ratio [INR] of prothrombin time) < 1.1 x institutional upper limit of normal
- Note: Patients on full-dose anticoagulants (e.g., warfarin) are eligible provided that both of the following criteria are met: a) the patient has an in-range INR (usually between 2 and 3) on a stable dose of oral anticoagulant or on a stable dose of low molecular weight heparin, and b) the patient has no active bleeding or pathological condition that carries a high risk of bleeding (e.g., tumor involving major vessels or known varices)
-
International normalized ration (INR) > 1.5 (unless the patient is on full-dose warfarin)
-
Receiving enzyme-inducing antiepileptic drugs (EIAEDs; e.g., phenytoin, fosphenytoin, carbamazepine, phenobarbital, or primidone) or any other potent cytochrome P450, family 3, subfamily A, polypeptide 4 (CYP3A4) inducer, such as rifampin or St. John?s wort
-
Any condition (e.g., gastrointestinal tract disease resulting in an inability to take oral medication or a requirement for IV alimentation, prior surgical procedures affecting absorption, or active peptic ulcer disease) that impairs their ability to swallow pills
-
Hypertension with systolic blood pressure of > 140 mmHg or diastolic pressure > 90 mmHg; however, patients with well-controlled hypertension are eligible
-
Uncontrolled infection
-
Pregnant women
-
Nursing women
-
Men or women of childbearing potential who are unwilling to employ adequate contraception
-
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 and for the duration of study participation; should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately
-
Known hypersensitivity to any of the components of CCI-779 or sorafenib
-
Other active malignancy
-
Uncontrolled intercurrent illness, including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, psychiatric illness/social situation that would preclude study compliance with study requirements
-
Immunocompromised patients (other than that related to the use of corticosteroids) including patients known to be human immunodeficiency virus (HIV) positive; HIV-positive patients on combination antiretroviral therapy are ineligible
-
Receiving any investigational agents other than CCI-779 and sorafenib
-
Significant intratumoral, intracerebral, or subarachnoid hemorrhage on baseline MRI or CT, or other history of significant intratumoral, intracerebral, or subarachnoid hemorrhage
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Group I (sorafenib tosylate, temsirolimus) Sorafenib Tosylate Patients receive sorafenib tosylate and temsirolimus as in Phase I. Group III (sorafenib tosylate, temsirolimus, anti-VEGF) Laboratory Biomarker Analysis Patients who have received prior anti-VEGF therapy and are not undergoing surgery receive sorafenib tosylate and temsirolimus as in Phase I. Group II (sorafenib tosylate, temsirolimus, surgery) Sorafenib Tosylate Patients receive sorafenib tosylate PO BID on days 1-8 and temsirolimus IV over 30 minutes on day 1. Patients undergo surgery on day 8. After recovering from surgery, patients receive sorafenib tosylate and temsirolimus as in Phase I. Group I (sorafenib tosylate, temsirolimus) Laboratory Biomarker Analysis Patients receive sorafenib tosylate and temsirolimus as in Phase I. Group II (sorafenib tosylate, temsirolimus, surgery) Conventional Surgery Patients receive sorafenib tosylate PO BID on days 1-8 and temsirolimus IV over 30 minutes on day 1. Patients undergo surgery on day 8. After recovering from surgery, patients receive sorafenib tosylate and temsirolimus as in Phase I. Group II (sorafenib tosylate, temsirolimus, surgery) Laboratory Biomarker Analysis Patients receive sorafenib tosylate PO BID on days 1-8 and temsirolimus IV over 30 minutes on day 1. Patients undergo surgery on day 8. After recovering from surgery, patients receive sorafenib tosylate and temsirolimus as in Phase I. Group III (sorafenib tosylate, temsirolimus, anti-VEGF) Sorafenib Tosylate Patients who have received prior anti-VEGF therapy and are not undergoing surgery receive sorafenib tosylate and temsirolimus as in Phase I. Group I (sorafenib tosylate, temsirolimus) Temsirolimus Patients receive sorafenib tosylate and temsirolimus as in Phase I. Group II (sorafenib tosylate, temsirolimus, surgery) Temsirolimus Patients receive sorafenib tosylate PO BID on days 1-8 and temsirolimus IV over 30 minutes on day 1. Patients undergo surgery on day 8. After recovering from surgery, patients receive sorafenib tosylate and temsirolimus as in Phase I. Group III (sorafenib tosylate, temsirolimus, anti-VEGF) Temsirolimus Patients who have received prior anti-VEGF therapy and are not undergoing surgery receive sorafenib tosylate and temsirolimus as in Phase I.
- Primary Outcome Measures
Name Time Method Progression-free Survival At 6 months The primary endpoint is the proportion of patients alive and progression-free 6 months after study treatment initiation.
If more than 41 evaluable patients are accrued in group 1 or group 3, the additional patients will not be used to evaluate the decision rule for that group or otherwise used in any decision-making processes. However, they will be included in the final point and confidence interval estimates for that group.
The 'success' probability, i.e., 6-month progression-free survival percentage, for each of group 1 and group 3 will be estimated as the number of evaluable patients still alive at 6 months divided by the total number of evaluable patients followed for at least 6 months. Ninety-five percent confidence intervals for the 'success' probability will be calculated according to the approach of Duffy and Santner.
Progression is defined as a 25% increase in product of perpendicular diameters of contrast enhancement or mass or appearance of new lesions.
- Secondary Outcome Measures
Name Time Method Overall Survival From start of study registration to death due to any cause or until last follow-up, up to 5 years The overall survival distribution will be estimated using the method of Kaplan-Meier.
Objective Response, as Determined by a Neurological Exam, MRI, and/or CT Measurement Up to 5 years The proportion of patients in each response category will be summarized and 90% confidence intervals calculated assuming that the incidence of response is binomially distributed.
Progression-free Survival Time from study registration to date of disease progression or last follow-up, assessed up to 5 years Kaplan-Meier survival curves will be used to estimate progression-time distributions.
Trial Locations
- Locations (189)
Graham Hospital Association
🇺🇸Canton, Illinois, United States
Illinois CancerCare-Macomb
🇺🇸Macomb, Illinois, United States
Providence Alaska Medical Center
🇺🇸Anchorage, Alaska, United States
Mayo Clinic in Arizona
🇺🇸Scottsdale, Arizona, United States
Saint Francis Hospital
🇺🇸Greenville, South Carolina, United States
Avera McKennan Hospital and University Health Center
🇺🇸Sioux Falls, South Dakota, United States
Rapid City Regional Hospital
🇺🇸Rapid City, South Dakota, United States
Spartanburg Medical Center
🇺🇸Spartanburg, South Carolina, United States
Rush University Medical Center
🇺🇸Chicago, Illinois, United States
Illinois CancerCare-Bloomington
🇺🇸Bloomington, Illinois, United States
Rush - Copley Medical Center
🇺🇸Aurora, Illinois, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸Boise, Idaho, United States
Saint Joseph Medical Center
🇺🇸Bloomington, Illinois, United States
Galesburg Cottage Hospital
🇺🇸Galesburg, Illinois, United States
Illinois CancerCare-Galesburg
🇺🇸Galesburg, Illinois, United States
Illinois CancerCare-Carthage
🇺🇸Carthage, Illinois, United States
Illinois CancerCare-Eureka
🇺🇸Eureka, Illinois, United States
Illinois CancerCare-Havana
🇺🇸Havana, Illinois, United States
Mason District Hospital
🇺🇸Havana, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Canton
🇺🇸Canton, Illinois, United States
Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Illinois CancerCare-Kewanee Clinic
🇺🇸Kewanee, Illinois, United States
Bromenn Regional Medical Center
🇺🇸Normal, Illinois, United States
Holy Family Medical Center
🇺🇸Monmouth, Illinois, United States
Joliet Oncology-Hematology Associates Limited
🇺🇸Joliet, Illinois, United States
Memorial Hospital
🇺🇸Carthage, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸Ottawa, Illinois, United States
Eureka Hospital
🇺🇸Eureka, Illinois, United States
Illinois CancerCare-Princeton
🇺🇸Princeton, Illinois, United States
Illinois CancerCare-Pekin
🇺🇸Pekin, Illinois, United States
Cancer Center of Kansas-Independence
🇺🇸Independence, Kansas, United States
Illinois CancerCare-Peoria
🇺🇸Peoria, Illinois, United States
Mercy Medical Center - North Iowa
🇺🇸Mason City, Iowa, United States
OSF Saint Francis Medical Center
🇺🇸Peoria, Illinois, United States
Heartland Cancer Research NCORP
🇺🇸Decatur, Illinois, United States
Illinois CancerCare-Community Cancer Center
🇺🇸Normal, Illinois, United States
Franciscan Saint Anthony Health-Michigan City
🇺🇸Michigan City, Indiana, United States
Illinois CancerCare-Monmouth
🇺🇸Monmouth, Illinois, United States
Hopedale Medical Complex - Hospital
🇺🇸Hopedale, Illinois, United States
Ottawa Regional Hospital and Healthcare Center
🇺🇸Ottawa, Illinois, United States
Illinois CancerCare-Spring Valley
🇺🇸Spring Valley, Illinois, United States
OSF Saint Francis Radiation Oncology at Pekin Cancer Treatment Center
🇺🇸Pekin, Illinois, United States
Kewanee Hospital
🇺🇸Kewanee, Illinois, United States
Saint Mary Mercy Hospital
🇺🇸Livonia, Michigan, United States
Essentia Health Cancer Center
🇺🇸Duluth, Minnesota, United States
Siouxland Regional Cancer Center
🇺🇸Sioux City, Iowa, United States
Metro Health Hospital
🇺🇸Wyoming, Michigan, United States
Sanford Clinic North-Bemidgi
🇺🇸Bemidji, Minnesota, United States
Lakeview Hospital
🇺🇸Stillwater, Minnesota, United States
Ridgeview Medical Center
🇺🇸Waconia, Minnesota, United States
Sanford Broadway Medical Center
🇺🇸Fargo, North Dakota, United States
Sparrow Hospital
🇺🇸Lansing, Michigan, United States
Munson Medical Center
🇺🇸Traverse City, Michigan, United States
Saint John Macomb-Oakland Hospital
🇺🇸Warren, Michigan, United States
Fairview Ridges Hospital
🇺🇸Burnsville, Minnesota, United States
Southwest Medical Center
🇺🇸Liberal, Kansas, United States
Mercy Health Mercy Campus
🇺🇸Muskegon, Michigan, United States
Swenson, Wade II, MD (UIA Investigator)
🇺🇸Fergus Falls, Minnesota, United States
Saint John's Hospital - Healtheast
🇺🇸Maplewood, Minnesota, United States
Cancer Center of Kansas-Liberal
🇺🇸Liberal, Kansas, United States
Etzell, Paul S MD (UIA Investigator)
🇺🇸Fergus Falls, Minnesota, United States
Saint Joseph Mercy Oakland
🇺🇸Pontiac, Michigan, United States
Unity Hospital
🇺🇸Fridley, Minnesota, United States
Medini, Eitan MD (UIA Investigator)
🇺🇸Alexandria, Minnesota, United States
Essentia Health Saint Mary's Medical Center
🇺🇸Duluth, Minnesota, United States
Saint Mary's of Michigan
🇺🇸Saginaw, Michigan, United States
Spectrum Health Big Rapids Hospital
🇺🇸Big Rapids, Michigan, United States
Lake Huron Medical Center
🇺🇸Port Huron, Michigan, United States
Green Bay Oncology - Iron Mountain
🇺🇸Iron Mountain, Michigan, United States
Miller-Dwan Hospital
🇺🇸Duluth, Minnesota, United States
Park Nicollet Clinic - Saint Louis Park
🇺🇸Saint Louis Park, Minnesota, United States
Lehigh Valley Hospital - Muhlenberg
🇺🇸Bethlehem, Pennsylvania, United States
AnMed Health Hospital
🇺🇸Anderson, South Carolina, United States
Virginia Mason Medical Center
🇺🇸Seattle, Washington, United States
Saint Joseph's Hospital - Healtheast
🇺🇸Saint Paul, Minnesota, United States
Nebraska Cancer Research Center
🇺🇸Lincoln, Nebraska, United States
Coborn Cancer Center at Saint Cloud Hospital
🇺🇸Saint Cloud, Minnesota, United States
Minnesota Oncology Hematology PA-Woodbury
🇺🇸Woodbury, Minnesota, United States
Sanford Bismarck Medical Center
🇺🇸Bismarck, North Dakota, United States
Geisinger Medical Group
🇺🇸State College, Pennsylvania, United States
Rutherford Hospital
🇺🇸Rutherfordton, North Carolina, United States
Saint Francis Regional Medical Center
🇺🇸Shakopee, Minnesota, United States
Saint Cloud Hospital
🇺🇸Saint Cloud, Minnesota, United States
Metro Minnesota Community Oncology Research Consortium
🇺🇸Saint Louis Park, Minnesota, United States
Lehigh Valley Hospital-Cedar Crest
🇺🇸Allentown, Pennsylvania, United States
New Ulm Medical Center
🇺🇸New Ulm, Minnesota, United States
United Hospital
🇺🇸Saint Paul, Minnesota, United States
AnMed Health Cancer Center
🇺🇸Anderson, South Carolina, United States
Sanford Clinic North-Fargo
🇺🇸Fargo, North Dakota, United States
Holy Family Memorial Hospital
🇺🇸Manitowoc, Wisconsin, United States
Geisinger Medical Center-Cancer Center Hazleton
🇺🇸Hazleton, Pennsylvania, United States
Avera Cancer Institute
🇺🇸Sioux Falls, South Dakota, United States
Saint Vincent Hospital Cancer Center Green Bay
🇺🇸Green Bay, Wisconsin, United States
Green Bay Oncology - Sturgeon Bay
🇺🇸Sturgeon Bay, Wisconsin, United States
University of Virginia Cancer Center
🇺🇸Charlottesville, Virginia, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸Sioux Falls, South Dakota, United States
Green Bay Oncology - Oconto Falls
🇺🇸Oconto Falls, Wisconsin, United States
Minnesota Cooperative Group Outreach Program
🇺🇸Minneapolis, Minnesota, United States
Hennepin County Medical Center
🇺🇸Minneapolis, Minnesota, United States
Via Christi Regional Medical Center
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas-Kingman
🇺🇸Kingman, Kansas, United States
Cancer Center of Kansas - Wellington
🇺🇸Wellington, Kansas, United States
Roger Maris Cancer Center
🇺🇸Fargo, North Dakota, United States
Cancer Center of Kansas - Chanute
🇺🇸Chanute, Kansas, United States
Cancer Center of Kansas - El Dorado
🇺🇸El Dorado, Kansas, United States
Cancer Center of Kansas - Newton
🇺🇸Newton, Kansas, United States
Cancer Center of Kansas - Dodge City
🇺🇸Dodge City, Kansas, United States
Associates In Womens Health
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas - Pratt
🇺🇸Pratt, Kansas, United States
Lawrence Memorial Hospital
🇺🇸Lawrence, Kansas, United States
Cancer Center of Kansas - McPherson
🇺🇸McPherson, Kansas, United States
Fairview-Southdale Hospital
🇺🇸Edina, Minnesota, United States
Meeker County Memorial Hospital
🇺🇸Litchfield, Minnesota, United States
North Memorial Medical Health Center
🇺🇸Robbinsdale, Minnesota, United States
Lake Region Healthcare Corporation-Cancer Care
🇺🇸Fergus Falls, Minnesota, United States
Hutchinson Area Health Care
🇺🇸Hutchinson, Minnesota, United States
Abbott-Northwestern Hospital
🇺🇸Minneapolis, Minnesota, United States
Virginia Piper Cancer Institute
🇺🇸Minneapolis, Minnesota, United States
Woodwinds Health Campus
🇺🇸Woodbury, Minnesota, United States
Mayo Clinic in Florida
🇺🇸Jacksonville, Florida, United States
Smilow Cancer Hospital Care Center at Saint Francis
🇺🇸Hartford, Connecticut, United States
Saint Anthony Memorial Hospital
🇺🇸Effingham, Illinois, United States
Community Cancer Center Foundation
🇺🇸Normal, Illinois, United States
Proctor Hospital
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Peru
🇺🇸Peru, Illinois, United States
Pekin Hospital
🇺🇸Pekin, Illinois, United States
Perry Memorial Hospital
🇺🇸Princeton, Illinois, United States
Saint Margaret's Hospital
🇺🇸Spring Valley, Illinois, United States
Saint Luke's Regional Medical Center
🇺🇸Sioux City, Iowa, United States
Hospital District Sixth of Harper County
🇺🇸Anthony, Kansas, United States
Cancer Center of Kansas - Fort Scott
🇺🇸Fort Scott, Kansas, United States
Cancer Center of Kansas - Parsons
🇺🇸Parsons, Kansas, United States
Cancer Center of Kansas - Salina
🇺🇸Salina, Kansas, United States
Cancer Center of Kansas-Wichita Medical Arts Tower
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas - Wichita
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas - Winfield
🇺🇸Winfield, Kansas, United States
Wichita NCI Community Oncology Research Program
🇺🇸Wichita, Kansas, United States
Bronson Battle Creek
🇺🇸Battle Creek, Michigan, United States
Green Bay Oncology - Escanaba
🇺🇸Escanaba, Michigan, United States
Hurley Medical Center
🇺🇸Flint, Michigan, United States
Cancer Research Consortium of West Michigan NCORP
🇺🇸Grand Rapids, Michigan, United States
Mercy Health Saint Mary's
🇺🇸Grand Rapids, Michigan, United States
Genesys Regional Medical Center-West Flint Campus
🇺🇸Flint, Michigan, United States
Spectrum Health at Butterworth Campus
🇺🇸Grand Rapids, Michigan, United States
Allegiance Health
🇺🇸Jackson, Michigan, United States
Minnesota Oncology Hematology PA-Maplewood
🇺🇸Maplewood, Minnesota, United States
Regions Hospital
🇺🇸Saint Paul, Minnesota, United States
Saint Alexius Medical Center
🇺🇸Bismarck, North Dakota, United States
Mid Dakota Clinic
🇺🇸Bismarck, North Dakota, United States
Altru Cancer Center
🇺🇸Grand Forks, North Dakota, United States
Geisinger Medical Center
🇺🇸Danville, Pennsylvania, United States
Geisinger Wyoming Valley/Henry Cancer Center
🇺🇸Wilkes-Barre, Pennsylvania, United States
Sanford Cancer Center Oncology Clinic
🇺🇸Sioux Falls, South Dakota, United States
Medical X-Ray Center
🇺🇸Sioux Falls, South Dakota, United States
Saint Vincent Hospital Cancer Center at Saint Mary's
🇺🇸Green Bay, Wisconsin, United States
Green Bay Oncology at Saint Vincent Hospital
🇺🇸Green Bay, Wisconsin, United States
Bay Area Medical Center
🇺🇸Marinette, Wisconsin, United States
Green Bay Oncology Limited at Saint Mary's Hospital
🇺🇸Green Bay, Wisconsin, United States
HSHS Saint Nicholas Hospital
🇺🇸Sheboygan, Wisconsin, United States
Beaumont Hospital-Dearborn
🇺🇸Dearborn, Michigan, United States
Genesys Hurley Cancer Institute
🇺🇸Flint, Michigan, United States
Mcdonough District Hospital
🇺🇸Macomb, Illinois, United States
Saint Joseph Mercy Hospital
🇺🇸Ann Arbor, Michigan, United States
Saint John Hospital and Medical Center
🇺🇸Detroit, Michigan, United States
Alegent Health Bergan Mercy Medical Center
🇺🇸Omaha, Nebraska, United States
Michigan Cancer Research Consortium NCORP
🇺🇸Ann Arbor, Michigan, United States
Mayo Clinic
🇺🇸Rochester, Minnesota, United States
Alegent Health Lakeside Hospital
🇺🇸Omaha, Nebraska, United States
Missouri Valley Cancer Consortium
🇺🇸Omaha, Nebraska, United States
Alegent Health Immanuel Medical Center
🇺🇸Omaha, Nebraska, United States
Southeast Clinical Oncology Research (SCOR) Consortium NCORP
🇺🇸Winston-Salem, North Carolina, United States
Creighton University Medical Center
🇺🇸Omaha, Nebraska, United States
Illinois Valley Hospital
🇺🇸Peru, Illinois, United States
Carle Cancer Center
🇺🇸Urbana, Illinois, United States
The Carle Foundation Hospital
🇺🇸Urbana, Illinois, United States
McFarland Clinic PC-William R Bliss Cancer Center
🇺🇸Ames, Iowa, United States
Medical Oncology and Hematology Associates-West Des Moines
🇺🇸Clive, Iowa, United States
Mercy Medical Center-Sioux City
🇺🇸Sioux City, Iowa, United States
Oncology Associates at Mercy Medical Center
🇺🇸Cedar Rapids, Iowa, United States
Mercy Capitol
🇺🇸Des Moines, Iowa, United States
Iowa Methodist Medical Center
🇺🇸Des Moines, Iowa, United States
Iowa-Wide Oncology Research Coalition NCORP
🇺🇸Des Moines, Iowa, United States
Medical Oncology and Hematology Associates-Des Moines
🇺🇸Des Moines, Iowa, United States
Medical Oncology and Hematology Associates-Laurel
🇺🇸Des Moines, Iowa, United States
Mercy Medical Center - Des Moines
🇺🇸Des Moines, Iowa, United States
Iowa Lutheran Hospital
🇺🇸Des Moines, Iowa, United States
Virginia Commonwealth University/Massey Cancer Center
🇺🇸Richmond, Virginia, United States
Rice Memorial Hospital
🇺🇸Willmar, Minnesota, United States