Trametinib or Combination Chemotherapy in Treating Patients With Refractory or Advanced Biliary or Gallbladder Cancer or That Cannot Be Removed by Surgery

Phase 2

Completed

Conditions: BCLC Stage D Adult Hepatocellular Carcinoma
Recurrent Extrahepatic Bile Duct Carcinoma
Localized Non-Resectable Adult Liver Carcinoma
Stage III Childhood Hepatocellular Carcinoma
Stage IVA Gallbladder Cancer
Adult Cholangiocarcinoma
Advanced Adult Hepatocellular Carcinoma
Stage IV Childhood Hepatocellular Carcinoma
Recurrent Adult Liver Carcinoma
Stage IIIA Gallbladder Cancer

Interventions: Drug: Capecitabine
Drug: Trametinib
Drug: Fluorouracil
Other: Laboratory Biomarker Analysis
Drug: Leucovorin Calcium

Registration Number: NCT02042443

Lead Sponsor: National Cancer Institute (NCI)

Brief Summary: This randomized phase II trial studies how well trametinib or combination chemotherapy works in treating patients with refractory or advanced biliary or gallbladder cancer or that cannot be removed by surgery. Trametinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Drugs used in chemotherapy, such as fluorouracil, leucovorin calcium, and capecitabine, 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. It is not yet known whether giving trametinib is more effective than combination chemotherapy in treating patients with biliary or gallbladder cancer.

Detailed Description: PRIMARY OBJECTIVES:

I. To assess overall survival (OS) in patients with refractory advanced biliary cancer randomized to Arm 1: trametinib compared to those randomized to Arm 2: chemotherapy (either 5-fluorouracil \[fluorouracil\] and leucovorin \[leucovorin calcium\] or capecitabine).

SECONDARY OBJECTIVES:

I. To determine the frequency and severity of adverse events of trametinib in this patient population.

II. To assess response rate (RR) and progression-free survival (PFS) in patients randomized to Arm 1: trametinib and patients randomized to Arm 2: chemotherapy (fluorouracil \[5-FU\] or capecitabine in this patient population).

TERTIARY OBJECTIVES:

I. To determine if a 16-gene expression signature is predictive of mitogen-activated protein kinase kinase (MEK) efficacy as evidenced by improved RR, PFS, and OS.

II. To evaluate the effects of trametinib on the inflammatory cytokine and explore potential associations with response rate and survival.

III. To estimate lean soft tissue and fat mass weight gain as a result of treatment with trametinib vs. capecitabine in patients with advanced refractory biliary cancer.

IV. To bank tissue samples for other future correlative studies including next generation sequencing and whole genome methylation assays. NOTE: These potential future correlative studies will not be performed until an amended protocol with relevant detailed information including specific arms and assays is approved by Cancer Therapy Evaluation Program (CTEP).

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

ARM I: Patients receive trametinib orally (PO) once daily (QD) on days 1-21. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.

ARM II: Patients receive 1 of 2 treatment regimens at the discretion of the investigator.

ARM IIA: Patients receive leucovorin calcium intravenously (IV) over 2 hours and fluorouracil IV continuously over 46-48 hours on days 1 and 15. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.

ARM IIB: Patients receive capecitabine PO twice daily (BID) on days 1-14. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.

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

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 53

Inclusion Criteria

DISEASE RELATED CRITERIA
Patients must have histologically or cytologically documented carcinoma primary to the intra- or extra-hepatic biliary system or gall bladder with clinical and/or radiologic evidence of unresectable, locally advanced or metastatic disease; patients with ampullary carcinoma are not eligible
Patients must have measurable disease; computed tomography (CT) scans or magnetic resonance imaging (MRI)s used to assess measurable disease must have been completed within 28 days prior to registration; CT scans or MRIs used to assess non-measurable disease must have been completed within 42 days prior to registration; all disease must be assessed and documented on the Baseline Tumor Assessment Form (Response Evaluation Criteria in Solid Tumors [RECIST] 1.1)
PRIOR/CONCURRENT THERAPY CRITERIA
Patients must have completed any prior chemotherapy at least 21 days prior to registration and have recovered from any of the effects AND
- Patients must have experienced progression to no more than 1 prior regimen of systemic chemotherapy for advanced biliary cancer OR
- Patients who received adjuvant chemotherapy and had evidence of disease recurrence within 6 months of completion of the adjuvant treatment are also eligible; if patient received adjuvant treatment and had disease recurrence after 6 months, patients will only be eligible after failing one regimen of systemic chemotherapy used to treat the (unresectable or metastatic) disease recurrence
Patients must not have been treated with prior MEK inhibitors; prior 5-FU or capecitabine treatment is allowed only if given as a radiosensitizer concurrently with radiation therapy at least 12 weeks prior to registration or if given as part of any adjuvant therapy regimen >= 12 months prior to study enrollment
Patients must have no plans to receive concurrent chemotherapy, hormonal therapy, radiotherapy, immunotherapy or any other type of therapy (including herbal or natural supplements) for treatment of cancer while on this treatment protocol
For patients who have received prior cryotherapy, radiation therapy, radiofrequency ablation, therasphere, ethanol injection, transarterial chemoembolization (TACE) or photodynamic therapy, the following criteria must be met:
- 28 days have elapsed since that therapy (lesions that have not been treated with local therapy must be present and measureable)
CLINICAL/LABORATORY CRITERIA
Patients must have a Zubrod performance status of 0-1
Absolute neutrophil count (ANC) > 1000/mcL
Platelets > 100000/mcL
Total bilirubin =< 2.0 x the institutional upper limit of normal limits (IULN)
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) both =< 3 x IULN; if liver metastases are present, AST and ALT must be =< 5 x IULN
If the patient has had decompression of the biliary tree within the last 14 days, stability of the bilirubin level needs to be confirmed with two measurements that are within 5 to 7 days of each other; (the second measurement must be obtained within 7 days prior to registration;) both the first and second measurement must be =< 2.0 x IULN; stability is defined as the second measurement being no more than one point higher than the first
Patients must have adequate kidney function as evidenced by at least ONE of the following:
- Serum creatinine =< 1.5 x IULN within 28 days prior to registration
- Calculated creatinine clearance >= 50 ml/min for patients with creatinine level of 1.0-1.5 x IULN; the serum creatinine value used in the calculation must have been obtained within 28 days prior to registration
Patients with known history or current evidence of retinal vein occlusion (RVO) or retinal pigment epithelial detachment (RPED) are not eligible:
- History of RVO or RPED, or predisposing factors to RVO or RPED (e.g. such as uncontrolled glaucoma or ocular hypertension, uncontrolled systemic disease such as hypertension, diabetes mellitus, or history of hyperviscosity or hypercoagulability syndromes)
- Visible retinal pathology as assessed by ophthalmic exam that is considered a risk factor for RVO or RPED such as:
  - Evidence of new optic disc cupping
  - Evidence of new visual field defects
  - Intraocular pressure > 21 mmHg
- NOTE: ophthalmic exam is required for all patients; this exam should not be performed until or unless it is very clear the patient is otherwise eligible for registration; this exam should not be performed until or unless it is very clear the patient is otherwise eligible for registration
Patients must have echocardiogram and left ventricular ejection fraction (LVEF) >= institutional lower limit of normal (LLN) within 28 days prior to registration; this exam should not be performed until or unless it is very clear the patient is otherwise eligible for registration
Patients must not have uncontrolled or clinically significant cardiovascular disease including: myocardial infarction within past 6 months; uncontrolled angina within past 6 months; class II-IV New York Heart Association (NYHA) congestive heart failure; grade 3 cardiac valve dysfunction; cardiac arrhythmia not controlled by medication; history of stroke or transient ischemic attack within 6 months; history of arterial thrombotic event (ATE) of any type in the past 6 months; treatment-refractory hypertension defined as a blood pressure of systolic > 140 mmHg and/or diastolic > 90 mmHg which cannot be controlled with anti-hypertensive therapy; known intra-cardiac defibrillators; known cardiac metastases
Patients must have an electrocardiogram (ECG) within 28 days prior to registration; patients must have corrected QT interval (QTc) =< 500 msec; this exam should not be performed until or unless it is very clear the patient is otherwise eligible for registration
Must be able to swallow and retain orally-administered medication and does not have any clinically significant gastrointestinal abnormalities that may alter absorption such as malabsorption syndrome or major resection of the stomach or bowels
Must not have a known immediate or delayed hypersensitivity reaction or idiosyncrasy to drugs chemically related to trametinib, or excipients or to dimethyl sulfoxide (DMSO) or other agents used in study
Must not have active hepatitis B virus (HBV), or hepatitis C virus (HCV) infection (patients with chronic or cleared HBV and HCV infection are eligible)
Human immunodeficiency virus (HIV)-positive patients on combination antiretroviral therapy are ineligible
Patients must not be pregnant or nursing; women/men of reproductive potential must have agreed to use an effective contraceptive method while on study and for 4 months after discontinuation of study drug; 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
No other prior malignancy is allowed except for the following: adequately treated basal cell or squamous cell skin cancer, in situ cervical cancer, adequately treated stage I or II cancer from which the patient is currently in complete remission, or any other cancer from which the patient has been disease free for five years
SPECIMEN SUBMISSION CRITERIA
Patients must submit paraffin-embedded tissue and blood for banking within 28 days after registration; paraffin-embedded tissue from prior surgical resection or from a diagnostic biopsy is acceptable
REGULATORY CRITERIA
Patients or their legally authorized representative must be informed of the investigational nature of this study and must sign and give written informed consent in accordance with institutional and federal guidelines
As a part of the Oncology Patient Enrollment Network (OPEN) registration process the treating institution's identity is provided in order to ensure that the current (within 365 days) date of institutional review board approval for this study has been entered in the system

Exclusion Criteria

Not provided

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Chemotherapy	Laboratory Biomarker Analysis	Patients receive either A) leucovorin calcium IV over 2 hours and fluorouracil IV continuously over 46-48 hours on days 1 and 15 (courses repeat every 28 days); or B) capecitabine PO BID on days 1-14 (courses repeat every 21 days). Patients treated until disease progression or unacceptable toxicity.
Trametinib	Laboratory Biomarker Analysis	Patients receive trametinib PO QD on days 1-21. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.
Chemotherapy	Leucovorin Calcium	Patients receive either A) leucovorin calcium IV over 2 hours and fluorouracil IV continuously over 46-48 hours on days 1 and 15 (courses repeat every 28 days); or B) capecitabine PO BID on days 1-14 (courses repeat every 21 days). Patients treated until disease progression or unacceptable toxicity.
Trametinib	Trametinib	Patients receive trametinib PO QD on days 1-21. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.
Chemotherapy	Capecitabine	Patients receive either A) leucovorin calcium IV over 2 hours and fluorouracil IV continuously over 46-48 hours on days 1 and 15 (courses repeat every 28 days); or B) capecitabine PO BID on days 1-14 (courses repeat every 21 days). Patients treated until disease progression or unacceptable toxicity.
Chemotherapy	Fluorouracil	Patients receive either A) leucovorin calcium IV over 2 hours and fluorouracil IV continuously over 46-48 hours on days 1 and 15 (courses repeat every 28 days); or B) capecitabine PO BID on days 1-14 (courses repeat every 21 days). Patients treated until disease progression or unacceptable toxicity.

Primary Outcome Measures

Name	Time	Method
Overall Survival	Up to 2 years from registration	From date of registration to date of death due to any cause. Patients last known to be alive are censored at date of last contact.

Secondary Outcome Measures

Name	Time	Method
Number of Patients With Grade 3 Through Grade 5 Adverse Events That Are Related to Study Drug	Up to 2 years	Adverse event reporting followed the CTCAE (NCI Common Terminology Criteria for Adverse Events) Version 4.0. Only adverse events that are possibly, probably or definitely related to study drug are reported.
Objective Response Rate	Up to 2 years from registration	Confirmed response (CR) is two or more objective statuses of CR a minimum of four weeks apart documented before progression or symptomatic deterioration. Partial response (PR) is two or more objective statuses of PR or better a minimum of four weeks apart documented before progression or symptomatic deterioration. Unconfirmed CR is one objective status of CR documented before progression or symptomatic deterioration but not qualifying as CR or PR. Unconfirmed PR is one objective status of PR documented before progression or symptomatic deterioration but not qualifying as CR, PR or unconfirmed CR.
Progression-free Survival	Up to 2 years from registration	From date of registration to date of first documentation of progression or symptomatic deterioration, or death due to any cause. Patients last known to be alive and progression free are censored at date of last contact.

Trial Locations

Locations (294): Las Vegas Cancer Center-Henderson
🇺🇸
Henderson, Nevada, United States
Comprehensive Cancer Centers of Nevada-Southeast Henderson
🇺🇸
Henderson, Nevada, United States
Ohio State University Comprehensive Cancer Center
🇺🇸
Columbus, Ohio, United States
The Mark H Zangmeister Center
🇺🇸
Columbus, Ohio, United States
Newark Radiation Oncology
🇺🇸
Newark, Ohio, United States
Upper Valley Medical Center
🇺🇸
Troy, Ohio, United States
Greenville Health System Cancer Institute-Spartanburg
🇺🇸
Spartanburg, South Carolina, United States
Wellmont Holston Valley Hospital and Medical Center
🇺🇸
Kingsport, Tennessee, United States
Wellmont Medical Associates Oncology and Hematology-Kingsport
🇺🇸
Kingsport, Tennessee, United States
Providence Alaska Medical Center
🇺🇸
Anchorage, Alaska, United States
Alaska Breast Care and Surgery LLC
🇺🇸
Anchorage, Alaska, United States
Anchorage Oncology Centre
🇺🇸
Anchorage, Alaska, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸
Boise, Idaho, United States
Kootenai Cancer Center
🇺🇸
Post Falls, Idaho, United States
Charlotte Hungerford Hospital Center for Cancer Care
🇺🇸
Torrington, Connecticut, United States
Saint Patrick Hospital - Community Hospital
🇺🇸
Missoula, Montana, United States
Cancer and Blood Specialists-Henderson
🇺🇸
Henderson, Nevada, United States
Comprehensive Cancer Centers of Nevada - Henderson
🇺🇸
Henderson, Nevada, United States
Greenville Health System Cancer Institute-Eastside
🇺🇸
Greenville, South Carolina, United States
Greenville Health System Cancer Institute-Butternut
🇺🇸
Greenville, South Carolina, United States
Greenville Memorial Hospital
🇺🇸
Greenville, South Carolina, United States
Wellmont Bristol Regional Medical Center
🇺🇸
Bristol, Tennessee, United States
The Methodist Hospital System
🇺🇸
Houston, Texas, United States
University Medical Center of Southern Nevada
🇺🇸
Las Vegas, Nevada, United States
Nevada Cancer Research Foundation CCOP
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada-Summerlin
🇺🇸
Las Vegas, Nevada, United States
Cancer Therapy and Integrative Medicine
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada
🇺🇸
Las Vegas, Nevada, United States
Cancer and Blood Specialists-Tenaya
🇺🇸
Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-Tenaya
🇺🇸
Las Vegas, Nevada, United States
Kaiser Permanente-San Diego Zion
🇺🇸
San Diego, California, United States
Oncology Hematology Care Inc-Eden Park
🇺🇸
Cincinnati, Ohio, United States
Oncology Hematology Care Inc - Anderson
🇺🇸
Cincinnati, Ohio, United States
California Pacific Medical Center-Pacific Campus
🇺🇸
San Francisco, California, United States
Huntsman Cancer Institute/University of Utah
🇺🇸
Salt Lake City, Utah, United States
Alaska Women's Cancer Care
🇺🇸
Anchorage, Alaska, United States
Kaiser Permanente-Bellflower
🇺🇸
Bellflower, California, United States
Kaiser Permanente-Cadillac
🇺🇸
Los Angeles, California, United States
Alta Bates Summit Medical Center-Herrick Campus
🇺🇸
Berkeley, California, United States
Mills - Peninsula Hospitals
🇺🇸
Burlingame, California, United States
Los Angeles County-USC Medical Center
🇺🇸
Los Angeles, California, United States
Sutter Roseville Medical Center
🇺🇸
Roseville, California, United States
Palo Alto Medical Foundation-Santa Cruz
🇺🇸
Santa Cruz, California, United States
Sutter Pacific Medical Foundation
🇺🇸
Santa Rosa, California, United States
Kaiser Permanente
🇺🇸
Woodland Hills, California, United States
Smilow Cancer Hospital-Waterbury Care Center
🇺🇸
Waterbury, Connecticut, United States
Illinois CancerCare-Peoria
🇺🇸
Peoria, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸
Peoria, Illinois, United States
Radiation Oncology of Northern Illinois
🇺🇸
Ottawa, Illinois, United States
Illinois CancerCare-Pekin
🇺🇸
Pekin, Illinois, United States
Illinois CancerCare-Peru
🇺🇸
Peru, Illinois, United States
Salina Regional Health Center
🇺🇸
Salina, Kansas, United States
Boston Medical Center
🇺🇸
Boston, Massachusetts, United States
Oncology Hematology Care Inc-Crestview
🇺🇸
Crestview Hills, Kentucky, United States
Cancer Center of Kansas - Winfield
🇺🇸
Winfield, Kansas, United States
Lahey Hospital and Medical Center
🇺🇸
Burlington, Massachusetts, United States
Bronson Battle Creek
🇺🇸
Battle Creek, Michigan, United States
Weisberg Cancer Treatment Center
🇺🇸
Farmington Hills, Michigan, United States
Genesys Hurley Cancer Institute
🇺🇸
Flint, Michigan, United States
Sparrow Hospital
🇺🇸
Lansing, Michigan, United States
Saint Mary Mercy Hospital
🇺🇸
Livonia, Michigan, United States
Lakeland Community Hospital
🇺🇸
Niles, Michigan, United States
Saint Joseph Mercy Oakland
🇺🇸
Pontiac, Michigan, United States
Lake Huron Medical Center
🇺🇸
Port Huron, Michigan, United States
Lakeland Hospital
🇺🇸
Saint Joseph, Michigan, United States
Spectrum Health Reed City Hospital
🇺🇸
Reed City, Michigan, United States
Munson Medical Center
🇺🇸
Traverse City, Michigan, United States
Saint Mary's of Michigan
🇺🇸
Saginaw, Michigan, United States
Marie Yeager Cancer Center
🇺🇸
Saint Joseph, Michigan, United States
Southeast Cancer Center
🇺🇸
Cape Girardeau, Missouri, United States
Parkland Health Center-Bonne Terre
🇺🇸
Bonne Terre, Missouri, United States
Saint Francis Medical Center
🇺🇸
Cape Girardeau, Missouri, United States
Capital Region Medical Center-Goldschmidt Cancer Center
🇺🇸
Jefferson City, Missouri, United States
The University of Kansas Cancer Center-Lee's Summit
🇺🇸
Lee's Summit, Missouri, United States
Phelps County Regional Medical Center
🇺🇸
Rolla, Missouri, United States
Saint Louis Cancer and Breast Institute-South City
🇺🇸
Saint Louis, Missouri, United States
Saint John's Clinic-Rolla-Cancer and Hematology
🇺🇸
Rolla, Missouri, United States
Missouri Baptist Medical Center
🇺🇸
Saint Louis, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸
Saint Louis, Missouri, United States
Cancer Research for the Ozarks NCORP
🇺🇸
Springfield, Missouri, United States
Sainte Genevieve County Memorial Hospital
🇺🇸
Sainte Genevieve, Missouri, United States
Montana Cancer Consortium NCORP
🇺🇸
Billings, Montana, United States
Mercy Hospital Springfield
🇺🇸
Springfield, Missouri, United States
CoxHealth South Hospital
🇺🇸
Springfield, Missouri, United States
Missouri Baptist Outpatient Center-Sunset Hills
🇺🇸
Sunset Hills, Missouri, United States
Missouri Baptist Sullivan Hospital
🇺🇸
Sullivan, Missouri, United States
Bozeman Deaconess Hospital
🇺🇸
Bozeman, Montana, United States
Saint James Community Hospital and Cancer Treatment Center
🇺🇸
Butte, Montana, United States
Benefis Healthcare- Sletten Cancer Institute
🇺🇸
Great Falls, Montana, United States
Saint Peter's Community Hospital
🇺🇸
Helena, Montana, United States
Kalispell Regional Medical Center
🇺🇸
Kalispell, Montana, United States
21st Century Oncology - Henderson
🇺🇸
Henderson, Nevada, United States
Community Medical Hospital
🇺🇸
Missoula, Montana, United States
Cancer and Blood Specialists-Shadow
🇺🇸
Las Vegas, Nevada, United States
21st Century Oncology
🇺🇸
Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-San Martin
🇺🇸
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
Cancer and Blood Specialists-Fort Apache
🇺🇸
Las Vegas, Nevada, United States
Las Vegas Cancer Center-Medical Center
🇺🇸
Las Vegas, Nevada, United States
21st Century Oncology - Fort Apache
🇺🇸
Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-Centennial Hills
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Central Valley
🇺🇸
Las Vegas, Nevada, United States
University of New Mexico Cancer Center
🇺🇸
Albuquerque, New Mexico, United States
21st Century Oncology - Vegas Tenaya
🇺🇸
Las Vegas, Nevada, United States
Christus Saint Vincent Regional Cancer Center
🇺🇸
Santa Fe, New Mexico, United States
Columbia University/Herbert Irving Cancer Center
🇺🇸
New York, New York, United States
Cancer Care of Western North Carolina
🇺🇸
Asheville, North Carolina, United States
Asheville Hematology-Oncology Associates
🇺🇸
Asheville, North Carolina, United States
Mission Hospital-Memorial Campus
🇺🇸
Asheville, North Carolina, United States
Southeastern Medical Oncology Center-Clinton
🇺🇸
Clinton, North Carolina, United States
Wayne Memorial Hospital
🇺🇸
Goldsboro, North Carolina, United States
Southeastern Medical Oncology Center-Goldsboro
🇺🇸
Goldsboro, North Carolina, United States
Southeastern Medical Oncology Center-Jacksonville
🇺🇸
Jacksonville, North Carolina, United States
Southeastern Medical Oncology Center-Wilson
🇺🇸
Wilson, North Carolina, United States
Iredell Memorial Hospital
🇺🇸
Statesville, North Carolina, United States
Oncology Hematology Care Inc-Mercy West
🇺🇸
Cincinnati, Ohio, United States
Oncology Hematology Care Inc-Kenwood
🇺🇸
Cincinnati, Ohio, United States
Riverside Methodist Hospital
🇺🇸
Columbus, Ohio, United States
Columbus Oncology and Hematology Associates Inc
🇺🇸
Columbus, Ohio, United States
Columbus NCI Community Oncology Research Program
🇺🇸
Columbus, Ohio, United States
Grant Medical Center
🇺🇸
Columbus, Ohio, United States
Mount Carmel Health Center West
🇺🇸
Columbus, Ohio, United States
Miami Valley Hospital
🇺🇸
Dayton, Ohio, United States
Doctors Hospital
🇺🇸
Columbus, Ohio, United States
Good Samaritan Hospital - Dayton
🇺🇸
Dayton, Ohio, United States
Samaritan North Health Center
🇺🇸
Dayton, Ohio, United States
Delaware Health Center-Grady Cancer Center
🇺🇸
Delaware, Ohio, United States
Dayton NCI Community Oncology Research Program
🇺🇸
Dayton, Ohio, United States
Oncology Hematology Care Inc-Healthplex
🇺🇸
Fairfield, Ohio, United States
Atrium Medical Center-Middletown Regional Hospital
🇺🇸
Franklin, Ohio, United States
Delaware Radiation Oncology
🇺🇸
Delaware, Ohio, United States
Blanchard Valley Hospital
🇺🇸
Findlay, Ohio, United States
Licking Memorial Hospital
🇺🇸
Newark, Ohio, United States
Marietta Memorial Hospital
🇺🇸
Marietta, Ohio, United States
Knox Community Hospital
🇺🇸
Mount Vernon, Ohio, United States
Springfield Regional Medical Center
🇺🇸
Springfield, Ohio, United States
Genesis Healthcare System Cancer Care Center
🇺🇸
Zanesville, Ohio, United States
Clackamas Radiation Oncology Center
🇺🇸
Clackamas, Oregon, United States
Providence Milwaukie Hospital
🇺🇸
Milwaukie, Oregon, United States
Providence Willamette Falls Medical Center
🇺🇸
Oregon City, Oregon, United States
Providence Newberg Medical Center
🇺🇸
Newberg, Oregon, United States
Greenville Health System Cancer Institute-Easley
🇺🇸
Easley, South Carolina, United States
Swedish Medical Center-First Hill
🇺🇸
Seattle, Washington, United States
PeaceHealth Saint John Medical Center
🇺🇸
Longview, Washington, United States
PeaceHealth Southwest Medical Center
🇺🇸
Vancouver, Washington, United States
Big Horn Basin Cancer Center
🇺🇸
Cody, Wyoming, United States
Olathe Medical Center
🇺🇸
Olathe, Kansas, United States
University of Kansas Cancer Center
🇺🇸
Kansas City, Kansas, United States
Saint Catherine Hospital
🇺🇸
Garden City, Kansas, United States
Via Christi Regional Medical Center
🇺🇸
Wichita, Kansas, United States
Billings Clinic-Cody
🇺🇸
Cody, Wyoming, United States
Welch Cancer Center
🇺🇸
Sheridan, Wyoming, United States
Saint Rose Ambulatory and Surgery Center
🇺🇸
Great Bend, Kansas, United States
University of Rochester
🇺🇸
Rochester, New York, United States
Kaiser Permanente - Harbor City
🇺🇸
Harbor City, California, United States
Kaiser Permanente-Anaheim
🇺🇸
Anaheim, California, United States
Kaiser Permanente-Irvine
🇺🇸
Irvine, California, United States
UC Irvine Health/Chao Family Comprehensive Cancer Center
🇺🇸
Orange, California, United States
Sutter Cancer Research Consortium
🇺🇸
Novato, California, United States
Cancer Center of Kansas - Wichita
🇺🇸
Wichita, Kansas, United States
Wichita NCI Community Oncology Research Program
🇺🇸
Wichita, Kansas, United States
OSF Saint Francis Medical Center
🇺🇸
Peoria, Illinois, United States
Crossroads Cancer Center
🇺🇸
Effingham, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸
Ottawa, Illinois, United States
Cancer Center of Kansas - McPherson
🇺🇸
McPherson, Kansas, United States
Valley Radiation Oncology
🇺🇸
Peru, Illinois, United States
Lawrence Memorial Hospital
🇺🇸
Lawrence, Kansas, United States
Kaiser Permanente Hospital
🇺🇸
Fontana, California, United States
Kootenai Cancer Clinic
🇺🇸
Sandpoint, Idaho, United States
OSF Saint Francis Radiation Oncology at Pekin Cancer Treatment Center
🇺🇸
Pekin, Illinois, United States
Cancer Care Center of Decatur
🇺🇸
Decatur, Illinois, United States
Illinois CancerCare-Bloomington
🇺🇸
Bloomington, Illinois, United States
Cancer Center of Kansas - Dodge City
🇺🇸
Dodge City, Kansas, United States
City of Hope Comprehensive Cancer Center
🇺🇸
Duarte, California, United States
USC / Norris Comprehensive Cancer Center
🇺🇸
Los Angeles, California, United States
Smilow Cancer Hospital-Derby Care Center
🇺🇸
Derby, Connecticut, United States
Medical Oncology and Hematology Group PC-Guilford
🇺🇸
Guilford, Connecticut, United States
Katmai Oncology Group
🇺🇸
Anchorage, Alaska, United States
Illinois CancerCare-Canton
🇺🇸
Canton, Illinois, United States
Cancer Center of Kansas - El Dorado
🇺🇸
El Dorado, Kansas, United States
Beaumont Hospital-Dearborn
🇺🇸
Dearborn, Michigan, United States
Newman Regional Health
🇺🇸
Emporia, Kansas, United States
Palo Alto Medical Foundation-Camino Division
🇺🇸
Mountain View, California, United States
Cancer Center of Kansas-Independence
🇺🇸
Independence, Kansas, United States
Cancer Center of Kansas - Fort Scott
🇺🇸
Fort Scott, Kansas, United States
University of Kansas Cancer Center-Overland Park
🇺🇸
Overland Park, Kansas, United States
Memorial Hospital Colorado Springs
🇺🇸
Colorado Springs, Colorado, United States
Yale-New Haven Hospital North Haven Medical Center
🇺🇸
North Haven, Connecticut, United States
Decatur Memorial Hospital
🇺🇸
Decatur, Illinois, United States
Kaiser Permanente-San Diego Mission
🇺🇸
San Diego, California, United States
Illinois CancerCare-Macomb
🇺🇸
Macomb, Illinois, United States
Associates In Womens Health
🇺🇸
Wichita, Kansas, United States
Southern Illinois University School of Medicine
🇺🇸
Springfield, Illinois, United States
Cancer Center of Kansas-Kingman
🇺🇸
Kingman, Kansas, United States
Cancer Center of Kansas-Liberal
🇺🇸
Liberal, Kansas, United States
Cancer Center of Kansas - Newton
🇺🇸
Newton, Kansas, United States
Hays Medical Center
🇺🇸
Hays, Kansas, United States
Cancer Center of Kansas-Manhattan
🇺🇸
Manhattan, Kansas, United States
Palo Alto Medical Foundation Health Care
🇺🇸
Palo Alto, California, United States
Smilow Cancer Hospital Care Center at Saint Francis
🇺🇸
Hartford, Connecticut, United States
Cancer Center of Kansas - Parsons
🇺🇸
Parsons, Kansas, United States
Cancer Center of Kansas - Pratt
🇺🇸
Pratt, Kansas, United States
Kaiser Permanente - Panorama City
🇺🇸
Panorama City, California, United States
Cancer Center of Kansas - Wellington
🇺🇸
Wellington, Kansas, United States
Smilow Cancer Hospital-Orange Care Center
🇺🇸
Orange, Connecticut, United States
Cancer Center of Kansas-Wichita Medical Arts Tower
🇺🇸
Wichita, Kansas, United States
Good Samaritan Regional Health Center
🇺🇸
Mount Vernon, Illinois, United States
Saint Francis Hospital and Medical Center - Topeka
🇺🇸
Topeka, Kansas, United States
Via Christi Hospital-Pittsburg
🇺🇸
Pittsburg, Kansas, United States
Centralia Oncology Clinic
🇺🇸
Centralia, Illinois, United States
University of Kansas Cancer Center-West
🇺🇸
Kansas City, Kansas, United States
Memorial Hospital of Carbondale
🇺🇸
Carbondale, Illinois, United States
OSF Saint Francis Radiation Oncology at Peoria Cancer Center
🇺🇸
Peoria, Illinois, United States
Central Illinois Hematology Oncology Center
🇺🇸
Springfield, Illinois, United States
Cancer Center of Kansas - Chanute
🇺🇸
Chanute, Kansas, United States
Kaiser Permanente-San Marcos
🇺🇸
San Marcos, California, United States
Kootenai Medical Center
🇺🇸
Coeur d'Alene, Idaho, United States
Palo Alto Medical Foundation-Sunnyvale
🇺🇸
Sunnyvale, California, United States
Spectrum Health at Butterworth Campus
🇺🇸
Grand Rapids, Michigan, United States
Allegiance Health
🇺🇸
Jackson, Michigan, United States
Mercy Health Mercy Campus
🇺🇸
Muskegon, Michigan, United States
Hurley Medical Center
🇺🇸
Flint, Michigan, United States
Mercy Health Saint Mary's
🇺🇸
Grand Rapids, Michigan, United States
Saint John Macomb-Oakland Hospital
🇺🇸
Warren, Michigan, United States
Billings Clinic Cancer Center
🇺🇸
Billings, Montana, United States
Saint Vincent Healthcare
🇺🇸
Billings, Montana, United States
HealthCare Partners Medical Group Oncology/Hematology-Maryland Parkway
🇺🇸
Las Vegas, Nevada, United States
Radiation Oncology Centers of Nevada Central
🇺🇸
Las Vegas, Nevada, United States
Strecker Cancer Center-Belpre
🇺🇸
Belpre, Ohio, United States
Lowcountry Hematology Oncology PA-Mount Pleasant
🇺🇸
Mount Pleasant, South Carolina, United States
Greenville Health System Cancer Institute-Faris
🇺🇸
Greenville, South Carolina, United States
Adena Regional Medical Center
🇺🇸
Chillicothe, Ohio, United States
Greenville Health System Cancer Institute-Greer
🇺🇸
Greer, South Carolina, United States
Wellmont Medical Associates Oncology and Hematology-Johnson City
🇺🇸
Johnson City, Tennessee, United States
Oncology Hematology Care Inc-Blue Ash
🇺🇸
Cincinnati, Ohio, United States
Fairfield Medical Center
🇺🇸
Lancaster, Ohio, United States
Southwest VA Regional Cancer Center
🇺🇸
Norton, Virginia, United States
Kettering Medical Center
🇺🇸
Kettering, Ohio, United States
Greenville Health System Cancer Institute-Seneca
🇺🇸
Seneca, South Carolina, United States
Greenville Health System Cancer Institute-Andrews
🇺🇸
Greenville, South Carolina, United States
Gibbs Cancer Center-Pelham
🇺🇸
Greer, South Carolina, United States
Saint Francis Hospital
🇺🇸
Greenville, South Carolina, United States
Wayne Hospital
🇺🇸
Greenville, Ohio, United States
Spartanburg Medical Center
🇺🇸
Spartanburg, South Carolina, United States
The Don and Sybil Harrington Cancer Center
🇺🇸
Amarillo, Texas, United States
Southern Ohio Medical Center
🇺🇸
Portsmouth, Ohio, United States
Rocky Mountain Oncology
🇺🇸
Casper, Wyoming, United States
Saint Joseph Medical Center
🇺🇸
Bloomington, Illinois, United States
Kaiser Permanente-Baldwin Park
🇺🇸
Baldwin Park, California, United States
Sutter Auburn Faith Hospital
🇺🇸
Auburn, California, United States
Sutter Davis Hospital
🇺🇸
Davis, California, United States
Fremont - Rideout Cancer Center
🇺🇸
Marysville, California, United States
Kaiser Permanente-Riverside
🇺🇸
Riverside, California, United States
Illinois CancerCare-Eureka
🇺🇸
Eureka, Illinois, United States
Loyola University Medical Center
🇺🇸
Maywood, Illinois, United States
Illinois CancerCare-Kewanee Clinic
🇺🇸
Kewanee, Illinois, United States
Grady Memorial Hospital
🇺🇸
Delaware, Ohio, United States
Saint Ann's Hospital
🇺🇸
Westerville, Ohio, United States
Palo Alto Medical Foundation-Gynecologic Oncology
🇺🇸
Mountain View, California, United States
Western Illinois Cancer Treatment Center
🇺🇸
Galesburg, Illinois, United States
Illinois CancerCare-Princeton
🇺🇸
Princeton, Illinois, United States
Reid Health
🇺🇸
Richmond, Indiana, United States
Memorial Medical Center
🇺🇸
Springfield, Illinois, United States
Kaiser Permanente Los Angeles Medical Center
🇺🇸
Los Angeles, California, United States
Sutter Solano Medical Center/Cancer Center
🇺🇸
Vallejo, California, United States
Illinois CancerCare-Carthage
🇺🇸
Carthage, Illinois, United States
Illinois CancerCare-Galesburg
🇺🇸
Galesburg, Illinois, United States
Springfield Clinic
🇺🇸
Springfield, Illinois, United States
Moffitt Cancer Center
🇺🇸
Tampa, Florida, United States
Saint Joseph Mercy Hospital
🇺🇸
Ann Arbor, Michigan, United States
Michigan Cancer Research Consortium NCORP
🇺🇸
Ann Arbor, Michigan, United States
University of Michigan Comprehensive Cancer Center
🇺🇸
Ann Arbor, Michigan, United States
Wayne State University/Karmanos Cancer Institute
🇺🇸
Detroit, Michigan, United States
Saint John Hospital and Medical Center
🇺🇸
Detroit, Michigan, United States
Southeast Clinical Oncology Research (SCOR) Consortium NCORP
🇺🇸
Winston-Salem, North Carolina, United States
University of Oklahoma Health Sciences Center
🇺🇸
Oklahoma City, Oklahoma, United States
Providence Portland Medical Center
🇺🇸
Portland, Oregon, United States
Providence Saint Vincent Medical Center
🇺🇸
Portland, Oregon, United States
Oregon Health and Science University
🇺🇸
Portland, Oregon, United States
Sutter General Hospital
🇺🇸
Sacramento, California, United States
University of California Davis Comprehensive Cancer Center
🇺🇸
Sacramento, California, United States
University of Colorado Cancer Center - Anschutz Cancer Pavilion
🇺🇸
Aurora, Colorado, United States
Yale University
🇺🇸
New Haven, Connecticut, United States
The University of Kansas Cancer Center-South
🇺🇸
Kansas City, Missouri, United States
Roper Hospital
🇺🇸
Charleston, South Carolina, United States
Charleston Hematology Oncology Associates-Roper
🇺🇸
Charleston, South Carolina, United States
Lowcountry Hematology Oncology PA-North Charleston
🇺🇸
Charleston, South Carolina, United States
Truman Medical Center
🇺🇸
Kansas City, Missouri, United States
The University of Kansas Cancer Center-North
🇺🇸
Kansas City, Missouri, United States
Charleston Hematology Oncology Associates PA-St. Francis
🇺🇸
Charleston, South Carolina, United States
Lowcountry Hematology Oncology PA-West Ashley
🇺🇸
Charleston, South Carolina, United States
University of Florida
🇺🇸
Gainesville, Florida, United States
Cancer Center of Kansas - Salina
🇺🇸
Salina, Kansas, United States