Sapanisertib in Treating Patients With Metastatic or Refractory Pancreatic Neuroendocrine Tumor That Cannot Be Removed by Surgery

Phase 2

Completed

Conditions: Pancreatic Neuroendocrine Tumor G1
Pancreatic Neuroendocrine Tumor G2
Refractory Pancreatic Neuroendocrine Carcinoma

Interventions: Drug: Sapanisertib

Registration Number: NCT02893930

Lead Sponsor: National Cancer Institute (NCI)

Brief Summary: This phase II trial studies how well sapanisertib works in treating patients with pancreatic neuroendocrine tumor that has spread to other places in the body (metastatic), does not respond to treatment (refractory), or cannot be surgically removed. Drugs such as sapanisertib may stop the growth or shrink tumor cells by blocking some of the enzymes needed for cell growth.

Detailed Description: PRIMARY OBJECTIVE:

I. To evaluate overall response rate associated with sapanisertib (MLN0128 \[TAK-228\]) in patients with advanced pancreatic neuroendocrine tumors (PNETs).

SECONDARY ENDPOINTS:

I. To evaluate progression-free survival (PFS) associated with MLN0128 (TAK-228) in patients with advanced pancreatic neuroendocrine tumors (PNETs).

II. To measure the safety and tolerability of MLN0128 (TAK-228) in patients with advanced PNETs.

III. To evaluate disease control rate associated with MLN0128 (TAK-228) in patients with advanced PNETs.

IV. To measure duration of response rate associated with MLN0128 (TAK-228) in patients with advanced PNETs.

OUTLINE:

Patients receive sapanisertib orally (PO) once daily (QD) on days 1-28. Cycles repeat every 28 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, every 6 months for 1 year, and then yearly for 2 years.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 13

Inclusion Criteria

Patients must have unresectable or metastatic, histologically confirmed low or intermediate grade (Klimstra Criteria) pancreatic neuroendocrine tumor (PNET) with radiological evidence of disease progression since last treatment
Refractory disease to treatment with an mTOR inhibitor
Patients with uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements, are ineligible
Disease that is currently not amenable to surgery, radiation, or combined modality therapy with curative intent
Patients must not have poorly differentiated neuroendocrine carcinoma, high-grade neuroendocrine carcinoma, adenocarcinoid, goblet cell carcinoid and small cell carcinoma
Patients must have measurable disease
Documented radiological evidence for disease progression (measurable or nonmeasurable) =< 12 months prior to enrollment
- NOTE: If patient has had previous radiation to the marker lesion(s), there must be evidence of progression since the radiation; at least one measurable lesion as per Response Evaluation Criteria in Solid Tumors (RECIST)
Prior or concurrent therapy with somatostatin analogue (SSA) is permitted; a stable dose at least 2 months prior to study start and must continue on the stable dose while receiving study treatment; SSA is not considered as systemic treatment
Recovered from adverse events to grade 1 or less toxicity according to Common Terminology Criteria for Adverse Events version 4.0 (CTCAE 4.0) due to agents administered previously
- NOTE: Chemotherapy-induced alopecia and grade 2 neuropathy are acceptable
Patients must have Eastern Cooperative Oncology Group (ECOG) performance status of 0-1
Patients must be able to swallow intact capsules
Leukocytes >= 3,000/mm^3 (within less than or equal to 14 days prior to registration)
Absolute neutrophil count (ANC) >= 1.5 x 10^9/L (within less than or equal to 14 days prior to registration)
Hemoglobin >= 10 g/dL (within less than or equal to 14 days prior to registration)
Platelets >= 100 x 10^9/L (within less than or equal to 14 days prior to registration)
Total serum bilirubin =< institutional upper limit of normal (ULN) (within less than or equal to 14 days prior to registration)
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) =< 2.5 x ULN (within less than or equal to 14 days prior to registration)
Serum creatinine =< 1.5 X institutional ULN and creatinine clearance >= 60 ml/min (within less than or equal to 14 days prior to registration)
- NOTE: Creatinine clearance must be calculated using the Cockcroft-Gault equation
Glycosylated hemoglobin (HbA1c) < 7.0% (within less than or equal to 14 days prior to registration)
Fasting serum glucose =< 130 mg/dL (within less than or equal to 14 days prior to registration)
Fasting triglycerides =< 300 mg/dL (within less than or equal to 14 days prior to registration)
Diabetics are allowed if:
- Fasting blood glucose (FBG) =< 130 mg/dL (mmol/L), OR
- HbA1c =< 7%
Women must not be pregnant or breast-feeding due to potential harm to the fetus from MLN0128 (TAK-228); all females of childbearing potential must have a blood test or urine study within 7 days of registration to rule out pregnancy; a female of childbearing potential is any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months)
Women of child-bearing potential and men must agree to practice 1 highly effective method of contraception and 1 additional effective (barrier) method of contraception, at the same time, from the time of signing the informed consent through 90 days (for female patients) and 120 day (for male patients) after the last dose of study drug, or agree to completely abstain from heterosexual intercourse; should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately; men must agree not to donate sperm during the course of this study or within 120 days after receiving their last dose of study drug
Patients who have a history of brain metastasis are eligible for the study provided that all the following criteria are met:
- Brain metastases which have been treated
- No evidence of disease progression for >= 3 months before the first dose of study drug
- No hemorrhage after treatment
- Off-treatment with dexamethasone for 4 weeks before administration of the first dose of TAK-228
- No ongoing requirement for dexamethasone or anti-epileptic drugs
Voluntary written consent must be given before performance of any study related procedure not part of standard medical care, with the understanding that consent may be withdrawn by the patient at any time without prejudice to future medical care

Exclusion Criteria

Patient is INELIGIBLE if patient discontinued prior mTOR inhibitor due to toxicity
Patients must NOT have radiotherapy, or major surgery or active drug therapy for pNET (SSA permitted) within 4 weeks prior to study treatment start
Patient must NOT have had previous treatment with any PI3K or AKT inhibitor
NO hepatic artery embolization or cryoablation/radiofrequency ablation of hepatic metastasis within 2 months of study treatment start
Patients must NOT have previous or concurrent malignancy within 2 years; exceptions are made for patients who meet any of the following conditions:
- Adequately treated basal cell or squamous cell skin cancer, superficial bladder cancer OR
- Adequately treated stage I or II cancer currently in complete remission, or any other cancer that has been in complete remission for at least 2 years
No more than 3 prior systemic treatment regimens for advanced PNET
Patients with a history of the following within =< 6 months of study entry are NOT eligible:
- Ischemic myocardial event, including angina requiring therapy and artery revascularization procedures
- Ischemic cerebrovascular event, including transient ischemic attack (TIA) and artery revascularization procedures
- Requirement for inotropic support (excluding digoxin) or serious (uncontrolled) cardiac arrhythmia (including atrial flutter/fibrillation, ventricular fibrillation or ventricular tachycardia)
- New York Heart Association (NYHA) class III or IV heart failure
- Pulmonary embolism
Patients with known significant active cardiovascular or pulmonary disease at the time of study entry are INELIGIBLE including:
- Uncontrolled hypertension (i.e., systolic blood pressure >180 mm Hg, diastolic blood pressure > 95 mm Hg); use of anti-hypertensive agents to control hypertension before cycle1 day 1 is allowed
- Pulmonary hypertension
- Uncontrolled asthma or oxygen (O2) saturation < 90% by arterial blood gas analysis or pulse oximetry on room air
- QT syndrome, or torsades de pointes
- Significant valvular disease; severe regurgitation or stenosis by imaging independent of symptom control with medical intervention, or history of valve replacement
- Medically significant (symptomatic) bradycardia
- History of arrhythmia requiring an implantable cardiac defibrillator
- Baseline prolongation of the rate-corrected QT interval (QTc) (e.g., repeated demonstration of QTc interval > 480 milliseconds, or history of congenital long
Patients with known manifestations of malabsorption due to prior gastrointestinal (GI) surgery, GI disease, or for an unknown reason that may alter the absorption of MLN0128 (TAK-228) are INELIGIBLE
Human immunodeficiency virus (HIV)-positive patients on combination antiretroviral therapy are INELGIBLE because of the potential for pharmacokinetic interactions with MLN0128 (TAK-228)
NO treatment with strong inhibitors and/or inducers of cytochrome P450 (CYP) 3A4, or CYP2C19 within 1 week preceding the first dose of study drug
NO patients receiving systemic corticosteroids (either intravenous [IV] or oral steroids, excluding inhalers or low-dose hormone replacement therapy) within 1 week before administration of the first dose of study drug
Patients CANNOT have daily or chronic use of a proton pump inhibitor (PPI) and/or having taken a PPI within 7 days before receiving the first dose of study drug

Study & Design

Study Type: INTERVENTIONAL

Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Treatment (sapanisertib)	Sapanisertib	Patients receive sapanisertib PO QD on days 1-28. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.

Primary Outcome Measures

Name	Time	Method
Overall Response Rate	Assessed every 3 months for the first 2 years, every 6 months for the 3rd year, then annually up to 5 years	Response includes complete response (CR) and partial response (PR). CR is defined as disappearance of all lesions. Any pathological lymph nodes (whether target or non-target) must have reduction in short axis to \< 10 mm. PR is defined as at least a 30% decrease in the sum of the diameters of target lesions, taking as reference the baseline sum diameters.

Secondary Outcome Measures

Name	Time	Method
Progression-free Survival (PFS)	Assessed every 3 months for 2 years, every 6 months for the 3rd year, then annually up to 5 years	PFS was defined as time from study registration to disease progression (as defined by the RECIST criteria) or to death without progression, whichever occurred first. If date of death was greater than 4 months after the date of last documented to be free of progression or if patients were alive and free of progression at the time of the analysis, patients were censored at the time of last disease assessment. If such a date was not available, patients were censored at the time of registration. Progression is defined as at least a 20% increase in the sum of the diameters of target lesions, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on study). In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm. The appearance of one or more new lesions and/or unequivocal progression of existing non-target lesions is also considered progression.
Disease Control Rate	Assessed every 3 months for 2 years, every 6 months for the 3rd year, then annually up to 5 years	Disease control rate was defined as the proportion of patients with best overall response of CR, PR, or stable disease (SD) among all eligible patients who started protocol treatment. CR is defined as disappearance of all lesions. Any pathological lymph nodes (whether target or non-target) must have reduction in short axis to \< 10 mm. PR is defined as at least a 30% decrease in the sum of the diameters of target lesions, taking as reference the baseline sum diameters. SD is defined as neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as reference the smallest sum diameters while on study. To be assigned a status of stable disease, measurements must have met the stable disease criteria at least once after study entry at a minimum interval of 8 weeks.
Duration of Response	Assessed every 3 months for 2 years, every 6 months for the 3rd year, then annually up to 5 years	Duration of response was defined as the time from the onset of response (CR or PR, whichever status was recorded first) to first documentation of disease progression. Patients with responses but without documented disease progression were censored at the time of last disease evaluation. CR is defined as disappearance of all lesions. Any pathological lymph nodes (whether target or non-target) must have reduction in short axis to \< 10 mm. PR is defined as at least a 30% decrease in the sum of the diameters of target lesions, taking as reference the baseline sum diameters. Disease progression is defined as at least a 20% increase in the sum of the diameters of target lesions, taking as reference the smallest sum on study. In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm. The appearance of one or more new lesions and/or unequivocal progression of existing non-target lesions is also considered progression.

Trial Locations

Locations (403): Cedars Sinai Medical Center
🇺🇸
Los Angeles, California, United States
Bhadresh Nayak MD PC-Sterling Heights
🇺🇸
Sterling Heights, Michigan, United States
Central Care Cancer Center - Bolivar
🇺🇸
Bolivar, Missouri, United States
Southeastern Medical Oncology Center-Jacksonville
🇺🇸
Jacksonville, North Carolina, United States
Ohio State University Comprehensive Cancer Center
🇺🇸
Columbus, Ohio, 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 Cancer Center
🇺🇸
Las Vegas, Nevada, United States
Oncology Hematology Care Inc-Kenwood
🇺🇸
Cincinnati, Ohio, United States
Bethesda North Hospital
🇺🇸
Cincinnati, Ohio, United States
TriHealth Cancer Institute-Westside
🇺🇸
Cincinnati, Ohio, United States
TriHealth Cancer Institute-Anderson
🇺🇸
Cincinnati, Ohio, United States
Ann M Wierman MD LTD
🇺🇸
Las Vegas, Nevada, United States
Desert West Surgery
🇺🇸
Las Vegas, Nevada, United States
Cancer Therapy and Integrative Medicine
🇺🇸
Las Vegas, Nevada, United States
Cancer and Blood Specialists-Tenaya
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Northwest
🇺🇸
Las Vegas, Nevada, United States
GenesisCare USA - Vegas Tenaya
🇺🇸
Las Vegas, Nevada, United States
OptumCare Cancer Care at MountainView
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada-Summerlin
🇺🇸
Las Vegas, Nevada, United States
Summerlin Hospital Medical Center
🇺🇸
Las Vegas, Nevada, United States
PCR Oncology
🇺🇸
Arroyo Grande, California, United States
Rocky Mountain Cancer Centers-Penrose
🇺🇸
Colorado Springs, Colorado, United States
UCHealth Memorial Hospital Central
🇺🇸
Colorado Springs, Colorado, United States
Middlesex Hospital
🇺🇸
Middletown, Connecticut, United States
Mercy Medical Center
🇺🇸
Springfield, Massachusetts, United States
Sutter Cancer Centers Radiation Oncology Services-Vacaville
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Vacaville, California, United States
Mountain Blue Cancer Care Center
🇺🇸
Golden, Colorado, United States
Rocky Mountain Cancer Centers-Longmont
🇺🇸
Longmont, Colorado, United States
Southwest Oncology PC
🇺🇸
Durango, Colorado, United States
Sutter Roseville Medical Center
🇺🇸
Roseville, California, United States
Rocky Mountain Cancer Centers-Lakewood
🇺🇸
Lakewood, Colorado, United States
Palo Alto Medical Foundation-Sunnyvale
🇺🇸
Sunnyvale, California, United States
Rocky Mountain Cancer Centers - Pueblo
🇺🇸
Pueblo, Colorado, United States
Poudre Valley Hospital
🇺🇸
Fort Collins, Colorado, United States
Rocky Mountain Cancer Centers-Parker
🇺🇸
Parker, Colorado, United States
Littleton Adventist Hospital
🇺🇸
Littleton, Colorado, United States
Penrose-Saint Francis Healthcare
🇺🇸
Colorado Springs, Colorado, United States
CHI Saint Vincent Cancer Center Hot Springs
🇺🇸
Hot Springs, Arkansas, United States
Saint Mary Corwin Medical Center
🇺🇸
Pueblo, Colorado, United States
Sutter Pacific Medical Foundation
🇺🇸
Santa Rosa, California, United States
Mills-Peninsula Medical Center
🇺🇸
Burlingame, California, United States
Saint Anthony Hospital
🇺🇸
Lakewood, Colorado, United States
Good Samaritan Regional Health Center
🇺🇸
Mount Vernon, Illinois, United States
OSF Saint Francis Radiation Oncology at Peoria Cancer Center
🇺🇸
Peoria, Illinois, United States
Parker Adventist Hospital
🇺🇸
Parker, Colorado, United States
The Cancer Center of Hawaii-Pali Momi
🇺🇸
'Aiea, Hawaii, United States
OSF Saint Francis Radiation Oncology at Pekin Cancer Treatment Center
🇺🇸
Pekin, Illinois, United States
Northwestern Medicine Cancer Center Warrenville
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Warrenville, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸
Ottawa, Illinois, United States
Chancellor Center for Oncology
🇺🇸
Newburgh, Indiana, United States
Queen's Cancer Center - Pearlridge
🇺🇸
'Aiea, Hawaii, United States
Pali Momi Medical Center
🇺🇸
'Aiea, Hawaii, United States
Cancer Care Center of O'Fallon
🇺🇸
O'Fallon, Illinois, United States
Valley Radiation Oncology
🇺🇸
Peru, Illinois, United States
Illinois CancerCare-Pekin
🇺🇸
Pekin, Illinois, United States
Cancer Center of Kansas - Chanute
🇺🇸
Chanute, Kansas, United States
Cancer Center of Kansas-Kingman
🇺🇸
Kingman, Kansas, United States
Northwestern Medicine Lake Forest Hospital
🇺🇸
Lake Forest, Illinois, United States
Springfield Clinic
🇺🇸
Springfield, Illinois, United States
Illinois CancerCare-Macomb
🇺🇸
Macomb, Illinois, United States
Carle Physician Group-Mattoon/Charleston
🇺🇸
Mattoon, Illinois, United States
Deaconess Clinic Downtown
🇺🇸
Evansville, Indiana, United States
Illinois CancerCare-Peoria
🇺🇸
Peoria, Illinois, United States
Carle Cancer Center
🇺🇸
Urbana, Illinois, United States
Greater Regional Medical Center
🇺🇸
Creston, Iowa, United States
Reid Health
🇺🇸
Richmond, Indiana, United States
Cancer Center of Kansas-Manhattan
🇺🇸
Manhattan, Kansas, United States
Siouxland Regional Cancer Center
🇺🇸
Sioux City, Iowa, United States
Cancer Center of Kansas-Wichita Medical Arts Tower
🇺🇸
Wichita, Kansas, United States
The Carle Foundation Hospital
🇺🇸
Urbana, Illinois, United States
Cancer Center of Kansas - El Dorado
🇺🇸
El Dorado, Kansas, United States
Trinity Health IHA Medical Group Hematology Oncology - Brighton
🇺🇸
Brighton, Michigan, United States
Trinity Health Saint Mary Mercy Livonia Hospital
🇺🇸
Livonia, Michigan, United States
Alegent Health Mercy Hospital
🇺🇸
Council Bluffs, Iowa, United States
Cancer Center of Kansas - Fort Scott
🇺🇸
Fort Scott, Kansas, United States
Commonwealth Cancer Center-Corbin
🇺🇸
Corbin, Kentucky, United States
Southwest Illinois Health Services LLP
🇺🇸
Swansea, Illinois, United States
Rush-Copley Healthcare Center
🇺🇸
Yorkville, Illinois, United States
Medical Oncology and Hematology Associates-West Des Moines
🇺🇸
Clive, Iowa, United States
Mercy Cancer Center-West Lakes
🇺🇸
Clive, Iowa, United States
Trinity Health IHA Medical Group Hematology Oncology - Canton
🇺🇸
Canton, Michigan, United States
Lawrence Memorial Hospital
🇺🇸
Lawrence, Kansas, United States
Caro Cancer Center
🇺🇸
Caro, Michigan, United States
Cancer Center of Kansas-Independence
🇺🇸
Independence, Kansas, United States
Genesee Hematology Oncology PC
🇺🇸
Flint, Michigan, United States
Cancer Center of Kansas - Parsons
🇺🇸
Parsons, Kansas, United States
Cancer Center of Kansas - Wellington
🇺🇸
Wellington, Kansas, United States
Great Lakes Cancer Management Specialists-Doctors Park
🇺🇸
East China Township, Michigan, United States
Newland Medical Associates-Clarkston
🇺🇸
Clarkston, Michigan, United States
Weisberg Cancer Treatment Center
🇺🇸
Farmington Hills, Michigan, United States
Michigan Breast Specialists-Grosse Pointe Woods
🇺🇸
Grosse Pointe Woods, Michigan, United States
Genesys Hurley Cancer Institute
🇺🇸
Flint, Michigan, United States
Cancer Center of Kansas - Newton
🇺🇸
Newton, Kansas, United States
Cancer Center of Kansas - Pratt
🇺🇸
Pratt, Kansas, United States
Hematology Oncology Consultants-Clarkston
🇺🇸
Clarkston, Michigan, United States
Saint Joseph London
🇺🇸
London, Kentucky, United States
Flaget Memorial Hospital
🇺🇸
Bardstown, Kentucky, United States
Ascension Via Christi Hospitals Wichita
🇺🇸
Wichita, Kansas, United States
Cancer Center of Kansas - Wichita
🇺🇸
Wichita, Kansas, United States
Saint Joseph Mercy Brighton
🇺🇸
Brighton, Michigan, United States
Saint Joseph Mercy Canton
🇺🇸
Canton, Michigan, United States
Macomb Hematology Oncology PC
🇺🇸
Warren, Michigan, United States
Mercy Hospital
🇺🇸
Coon Rapids, Minnesota, United States
Saint Joseph Mercy Chelsea
🇺🇸
Chelsea, Michigan, United States
Ascension Saint Mary's Hospital
🇺🇸
Saginaw, Michigan, United States
21st Century Oncology-Pontiac
🇺🇸
Pontiac, Michigan, United States
Huron Medical Center PC
🇺🇸
Port Huron, Michigan, United States
Essentia Health Saint Mary's - Detroit Lakes Clinic
🇺🇸
Detroit Lakes, Minnesota, United States
Saint John Macomb-Oakland Hospital
🇺🇸
Warren, Michigan, United States
Hope Cancer Center
🇺🇸
Pontiac, Michigan, United States
Essentia Health Saint Mary's Medical Center
🇺🇸
Duluth, Minnesota, United States
Essentia Health Virginia Clinic
🇺🇸
Virginia, Minnesota, United States
Ascension Saint Joseph Hospital
🇺🇸
Tawas City, Michigan, United States
Saint Joseph Mercy Oakland
🇺🇸
Pontiac, Michigan, United States
Fairview Ridges Hospital
🇺🇸
Burnsville, Minnesota, United States
Advanced Breast Care Center PLLC
🇺🇸
Warren, Michigan, United States
Lake Region Healthcare Corporation-Cancer Care
🇺🇸
Fergus Falls, Minnesota, United States
Trinity Health IHA Medical Group Hematology Oncology Ann Arbor Campus
🇺🇸
Ypsilanti, Michigan, United States
Great Lakes Cancer Management Specialists-Rochester Hills
🇺🇸
Rochester Hills, Michigan, United States
Essentia Health Saint Joseph's Medical Center
🇺🇸
Brainerd, Minnesota, United States
GenesisCare USA - Las Vegas
🇺🇸
Las Vegas, Nevada, United States
Miller-Dwan Hospital
🇺🇸
Duluth, Minnesota, United States
Unity Hospital
🇺🇸
Fridley, Minnesota, United States
Lakeview Hospital
🇺🇸
Stillwater, Minnesota, United States
Midlands Community Hospital
🇺🇸
Papillion, Nebraska, United States
Carson Tahoe Regional Medical Center
🇺🇸
Carson City, Nevada, United States
Mercy Hospital Joplin
🇺🇸
Joplin, Missouri, United States
Comprehensive Cancer Centers of Nevada-Horizon Ridge
🇺🇸
Henderson, Nevada, United States
Radiation Oncology Centers of Nevada Central
🇺🇸
Las Vegas, Nevada, United States
Las Vegas Cancer Center-Medical Center
🇺🇸
Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-Maryland Parkway
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada
🇺🇸
Las Vegas, Nevada, United States
Radiation Oncology Centers of Nevada Southeast
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada-Southeast Henderson
🇺🇸
Henderson, Nevada, United States
Renown Regional Medical Center
🇺🇸
Reno, Nevada, United States
University of Rochester
🇺🇸
Rochester, New York, United States
Miami Valley Hospital
🇺🇸
Dayton, Ohio, United States
Kettering Medical Center
🇺🇸
Kettering, Ohio, United States
ProMedica Flower Hospital
🇺🇸
Sylvania, Ohio, United States
Rutgers Cancer Institute of New Jersey
🇺🇸
New Brunswick, New Jersey, United States
Franciscan Research Center-Northwest Medical Plaza
🇺🇸
Tacoma, Washington, United States
Lehigh Valley Hospital - Muhlenberg
🇺🇸
Bethlehem, Pennsylvania, United States
Armes Family Cancer Center
🇺🇸
Findlay, Ohio, United States
Saint Alphonsus Medical Center-Baker City
🇺🇸
Baker City, Oregon, United States
Saint Joseph Regional Cancer Center
🇺🇸
Bryan, Texas, United States
Lehigh Valley Hospital-Cedar Crest
🇺🇸
Allentown, Pennsylvania, United States
Highline Medical Center-Main Campus
🇺🇸
Burien, Washington, United States
Hope Cancer Care of Nevada-Pahrump
🇺🇸
Pahrump, Nevada, United States
Duluth Clinic Ashland
🇺🇸
Ashland, Wisconsin, United States
West Virginia University Healthcare
🇺🇸
Morgantown, West Virginia, United States
Wayne Hospital
🇺🇸
Greenville, Ohio, United States
Atrium Medical Center-Middletown Regional Hospital
🇺🇸
Franklin, Ohio, United States
Saint Mary's Regional Medical Center
🇺🇸
Reno, Nevada, United States
Good Samaritan Hospital - Dayton
🇺🇸
Dayton, Ohio, United States
Miami Valley Hospital South
🇺🇸
Centerville, Ohio, United States
Springfield Regional Cancer Center
🇺🇸
Springfield, Ohio, United States
Sanford South University Medical Center
🇺🇸
Fargo, North Dakota, United States
Sanford Cancer Center Oncology Clinic
🇺🇸
Sioux Falls, South Dakota, United States
Dayton Physicians LLC-Signal Point
🇺🇸
Middletown, Ohio, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸
Sioux Falls, South Dakota, United States
Greater Dayton Cancer Center
🇺🇸
Kettering, Ohio, United States
Dayton Physicians LLC-Wayne
🇺🇸
Greenville, Ohio, United States
Miami Valley Hospital North
🇺🇸
Dayton, Ohio, United States
Sanford Roger Maris Cancer Center
🇺🇸
Fargo, North Dakota, United States
Indu and Raj Soin Medical Center
🇺🇸
Beavercreek, Ohio, United States
Pulmonary Medicine Center of Chattanooga-Hixson
🇺🇸
Hixson, Tennessee, United States
Saint Elizabeth Hospital
🇺🇸
Enumclaw, Washington, United States
Northwest Wisconsin Cancer Center
🇺🇸
Ashland, Wisconsin, United States
Dayton Physician LLC-Miami Valley Hospital North
🇺🇸
Dayton, Ohio, United States
Harrison HealthPartners Hematology and Oncology-Bremerton
🇺🇸
Bremerton, Washington, United States
Saint Francis Hospital
🇺🇸
Federal Way, Washington, United States
Dayton Physicians LLC-Atrium
🇺🇸
Franklin, Ohio, United States
Dayton Physicians LLC-Upper Valley
🇺🇸
Troy, Ohio, United States
Sanford Bismarck Medical Center
🇺🇸
Bismarck, North Dakota, United States
Harrison HealthPartners Hematology and Oncology-Poulsbo
🇺🇸
Poulsbo, Washington, United States
Cancer Center of Western Wisconsin
🇺🇸
New Richmond, Wisconsin, United States
Marshfield Clinic-Wausau Center
🇺🇸
Wausau, Wisconsin, United States
Northwest Medical Specialties PLLC
🇺🇸
Tacoma, Washington, United States
Marshfield Medical Center-EC Cancer Center
🇺🇸
Eau Claire, Wisconsin, United States
Marshfield Medical Center-Rice Lake
🇺🇸
Rice Lake, Wisconsin, United States
Marshfield Medical Center - Weston
🇺🇸
Weston, Wisconsin, United States
Welch Cancer Center
🇺🇸
Sheridan, Wyoming, United States
Billings Clinic-Cody
🇺🇸
Cody, Wyoming, United States
California Pacific Medical Center-Pacific Campus
🇺🇸
San Francisco, California, United States
Abbott-Northwestern Hospital
🇺🇸
Minneapolis, Minnesota, United States
Health Partners Inc
🇺🇸
Minneapolis, Minnesota, United States
Hennepin County Medical Center
🇺🇸
Minneapolis, Minnesota, United States
Dayton Physicians LLC-Wilson
🇺🇸
Sidney, Ohio, United States
Mayo Clinic Hospital in Arizona
🇺🇸
Phoenix, Arizona, United States
Wayne State University/Karmanos Cancer Institute
🇺🇸
Detroit, Michigan, United States
Ascension Saint John Hospital
🇺🇸
Detroit, Michigan, United States
Mercy Hospital Oklahoma City
🇺🇸
Oklahoma City, Oklahoma, United States
Saint Peter's Community Hospital
🇺🇸
Helena, Montana, United States
Essentia Health Cancer Center-South University Clinic
🇺🇸
Fargo, North Dakota, United States
Sanford Broadway Medical Center
🇺🇸
Fargo, North Dakota, United States
Essentia Health - Jamestown Clinic
🇺🇸
Jamestown, North Dakota, United States
Cancer Center of Kansas-Liberal
🇺🇸
Liberal, Kansas, United States
Cancer Center of Kansas - McPherson
🇺🇸
McPherson, Kansas, United States
Cancer Center of Kansas - Salina
🇺🇸
Salina, Kansas, United States
Cancer Center of Kansas - Winfield
🇺🇸
Winfield, Kansas, United States
Fairview Southdale Hospital
🇺🇸
Edina, Minnesota, United States
New Ulm Medical Center
🇺🇸
New Ulm, Minnesota, United States
Essentia Health - Deer River Clinic
🇺🇸
Deer River, Minnesota, United States
United Hospital
🇺🇸
Saint Paul, Minnesota, United States
Longmont United Hospital
🇺🇸
Longmont, Colorado, United States
Rocky Mountain Cancer Centers-Thornton
🇺🇸
Thornton, Colorado, United States
Mercy Medical Center-West Lakes
🇺🇸
West Des Moines, Iowa, United States
Beaumont Hospital - Dearborn
🇺🇸
Dearborn, Michigan, United States
Allegiance Health
🇺🇸
Jackson, Michigan, United States
Hurley Medical Center
🇺🇸
Flint, Michigan, United States
Great Lakes Cancer Management Specialists-Macomb Medical Campus
🇺🇸
Macomb, Michigan, United States
Hope Cancer Clinic
🇺🇸
Livonia, Michigan, United States
Saint Mary's Oncology/Hematology Associates of Marlette
🇺🇸
Marlette, Michigan, United States
Monroe Cancer Center
🇺🇸
Monroe, Michigan, United States
Newland Medical Associates-Pontiac
🇺🇸
Pontiac, Michigan, United States
Michigan Breast Specialists-Warren
🇺🇸
Warren, Michigan, United States
Huron Gastroenterology PC
🇺🇸
Ypsilanti, Michigan, United States
HealthCare Partners Medical Group Oncology/Hematology-San Martin
🇺🇸
Las Vegas, Nevada, United States
Las Vegas Cancer Center-Henderson
🇺🇸
Henderson, Nevada, United States
GenesisCare USA - Fort Apache
🇺🇸
Las Vegas, Nevada, United States
OptumCare Cancer Care at Fort Apache
🇺🇸
Las Vegas, Nevada, United States
OSF Saint Francis Medical Center
🇺🇸
Peoria, Illinois, United States
Illinois CancerCare-Peru
🇺🇸
Peru, Illinois, United States
Illinois CancerCare-Princeton
🇺🇸
Princeton, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸
Peoria, Illinois, United States
Southern Illinois University School of Medicine
🇺🇸
Springfield, Illinois, United States
Mayo Clinic in Arizona
🇺🇸
Scottsdale, Arizona, United States
Sutter Auburn Faith Hospital
🇺🇸
Auburn, California, United States
Sutter Cancer Centers Radiation Oncology Services-Auburn
🇺🇸
Auburn, California, United States
Palo Alto Medical Foundation-Fremont
🇺🇸
Fremont, California, United States
Alta Bates Summit Medical Center-Herrick Campus
🇺🇸
Berkeley, California, United States
Sutter Davis Hospital
🇺🇸
Davis, California, United States
Palo Alto Medical Foundation-Camino Division
🇺🇸
Mountain View, California, United States
Memorial Medical Center
🇺🇸
Springfield, Illinois, United States
Palo Alto Medical Foundation-Gynecologic Oncology
🇺🇸
Mountain View, California, United States
Palo Alto Medical Foundation Health Care
🇺🇸
Palo Alto, California, United States
Stanford Cancer Institute Palo Alto
🇺🇸
Palo Alto, California, United States
Sutter Cancer Centers Radiation Oncology Services-Roseville
🇺🇸
Roseville, California, United States
Palo Alto Medical Foundation-Santa Cruz
🇺🇸
Santa Cruz, California, United States
Sutter Solano Medical Center/Cancer Center
🇺🇸
Vallejo, California, United States
Saint Alphonsus Cancer Care Center-Caldwell
🇺🇸
Caldwell, Idaho, United States
Walter Knox Memorial Hospital
🇺🇸
Emmett, Idaho, United States
Wilcox Memorial Hospital and Kauai Medical Clinic
🇺🇸
Lihue, Hawaii, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸
Boise, Idaho, United States
Kootenai Health - Coeur d'Alene
🇺🇸
Coeur d'Alene, Idaho, United States
Illinois CancerCare-Bloomington
🇺🇸
Bloomington, Illinois, United States
Rush - Copley Medical Center
🇺🇸
Aurora, Illinois, United States
Idaho Urologic Institute-Meridian
🇺🇸
Meridian, Idaho, United States
Saint Joseph Medical Center
🇺🇸
Bloomington, Illinois, United States
Saint Alphonsus Medical Center-Nampa
🇺🇸
Nampa, Idaho, United States
Kootenai Clinic Cancer Services - Post Falls
🇺🇸
Post Falls, Idaho, United States
Kootenai Cancer Clinic
🇺🇸
Sandpoint, Idaho, United States
Illinois CancerCare-Canton
🇺🇸
Canton, Illinois, United States
Memorial Hospital of Carbondale
🇺🇸
Carbondale, Illinois, United States
SIH Cancer Institute
🇺🇸
Carterville, Illinois, United States
Centralia Oncology Clinic
🇺🇸
Centralia, Illinois, United States
Illinois CancerCare-Carthage
🇺🇸
Carthage, Illinois, United States
Northwestern University
🇺🇸
Chicago, Illinois, United States
Carle on Vermilion
🇺🇸
Danville, Illinois, United States
Cancer Care Specialists of Illinois - Decatur
🇺🇸
Decatur, Illinois, United States
Decatur Memorial Hospital
🇺🇸
Decatur, Illinois, United States
Carle Physician Group-Effingham
🇺🇸
Effingham, Illinois, United States
Illinois CancerCare-Eureka
🇺🇸
Eureka, Illinois, United States
Crossroads Cancer Center
🇺🇸
Effingham, Illinois, United States
Illinois CancerCare-Galesburg
🇺🇸
Galesburg, Illinois, United States
Western Illinois Cancer Treatment Center
🇺🇸
Galesburg, Illinois, United States
Northwestern Medicine Cancer Center Delnor
🇺🇸
Geneva, Illinois, United States
Illinois CancerCare-Kewanee Clinic
🇺🇸
Kewanee, Illinois, United States
Cancer Center of Kansas - Dodge City
🇺🇸
Dodge City, Kansas, United States
Trinity Health IHA Medical Group Hematology Oncology - Chelsea Hospital
🇺🇸
Chelsea, Michigan, United States
Michigan Breast Specialists-Macomb Township
🇺🇸
Macomb, Michigan, United States
Sparrow Hospital
🇺🇸
Lansing, Michigan, United States
Lake Huron Medical Center
🇺🇸
Port Huron, Michigan, United States
Oncology Hematology Associates of Saginaw Valley PC
🇺🇸
Saginaw, Michigan, United States
Saint Mary's Oncology/Hematology Associates of West Branch
🇺🇸
West Branch, Michigan, United States
Essentia Health Cancer Center
🇺🇸
Duluth, Minnesota, United States
Minnesota Oncology Hematology PA-Maplewood
🇺🇸
Maplewood, Minnesota, United States
Essentia Health Hibbing Clinic
🇺🇸
Hibbing, Minnesota, United States
Essentia Health - Fosston
🇺🇸
Fosston, Minnesota, United States
Fairview Clinics and Surgery Center Maple Grove
🇺🇸
Maple Grove, Minnesota, United States
Saint John's Hospital - Healtheast
🇺🇸
Maplewood, Minnesota, United States
Monticello Cancer Center
🇺🇸
Monticello, Minnesota, United States
Essentia Health - Park Rapids
🇺🇸
Park Rapids, Minnesota, United States
Park Nicollet Clinic - Saint Louis Park
🇺🇸
Saint Louis Park, Minnesota, United States
Essentia Health Sandstone
🇺🇸
Sandstone, Minnesota, United States
Saint Francis Regional Medical Center
🇺🇸
Shakopee, Minnesota, United States
Sanford Thief River Falls Medical Center
🇺🇸
Thief River Falls, Minnesota, United States
Rice Memorial Hospital
🇺🇸
Willmar, Minnesota, United States
Fairview Lakes Medical Center
🇺🇸
Wyoming, Minnesota, United States
Minnesota Oncology Hematology PA-Woodbury
🇺🇸
Woodbury, Minnesota, United States
Sanford Cancer Center Worthington
🇺🇸
Worthington, Minnesota, United States
Cox Cancer Center Branson
🇺🇸
Branson, Missouri, United States
Saint Louis Cancer and Breast Institute-Ballwin
🇺🇸
Ballwin, Missouri, United States
Parkland Health Center-Bonne Terre
🇺🇸
Bonne Terre, Missouri, United States
Saint Francis Medical Center
🇺🇸
Cape Girardeau, Missouri, United States
Capital Region Southwest Campus
🇺🇸
Jefferson City, Missouri, United States
Heartland Regional Medical Center
🇺🇸
Saint Joseph, Missouri, United States
Mercy Clinic-Rolla-Cancer and Hematology
🇺🇸
Rolla, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸
Saint Louis, Missouri, United States
Mercy Hospital Springfield
🇺🇸
Springfield, Missouri, United States
Sainte Genevieve County Memorial Hospital
🇺🇸
Sainte Genevieve, Missouri, United States
CoxHealth South Hospital
🇺🇸
Springfield, Missouri, United States
Missouri Baptist Sullivan Hospital
🇺🇸
Sullivan, Missouri, United States
Missouri Baptist Outpatient Center-Sunset Hills
🇺🇸
Sunset Hills, Missouri, United States
Community Hospital of Anaconda
🇺🇸
Anaconda, Montana, United States
Billings Clinic Cancer Center
🇺🇸
Billings, Montana, United States
Great Falls Clinic
🇺🇸
Great Falls, Montana, United States
Heartland Hematology and Oncology
🇺🇸
Kearney, Nebraska, United States
Benefis Healthcare- Sletten Cancer Institute
🇺🇸
Great Falls, Montana, United States
Bozeman Deaconess Hospital
🇺🇸
Bozeman, Montana, United States
Kalispell Regional Medical Center
🇺🇸
Kalispell, Montana, United States
Community Medical Hospital
🇺🇸
Missoula, Montana, United States
CHI Health Good Samaritan
🇺🇸
Kearney, Nebraska, United States
CHI Health Saint Francis
🇺🇸
Grand Island, Nebraska, United States
Saint Elizabeth Regional Medical Center
🇺🇸
Lincoln, Nebraska, United States
Cancer and Blood Specialists-Henderson
🇺🇸
Henderson, Nevada, United States
Comprehensive Cancer Centers of Nevada - Henderson
🇺🇸
Henderson, Nevada, United States
OptumCare Cancer Care at Seven Hills
🇺🇸
Henderson, Nevada, United States
OptumCare Cancer Care at Charleston
🇺🇸
Las Vegas, Nevada, United States
University Medical Center of Southern Nevada
🇺🇸
Las Vegas, Nevada, United States
GenesisCare USA - Henderson
🇺🇸
Henderson, Nevada, United States
Cancer and Blood Specialists-Shadow
🇺🇸
Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-Tenaya
🇺🇸
Las Vegas, Nevada, United States
Mount Sinai Hospital
🇺🇸
New York, New York, United States
Radiation Oncology Associates
🇺🇸
Reno, Nevada, United States
Wayne Memorial Hospital
🇺🇸
Goldsboro, North Carolina, United States
Onslow Memorial Hospital
🇺🇸
Jacksonville, North Carolina, United States
Southeastern Medical Oncology Center-Clinton
🇺🇸
Clinton, North Carolina, United States
Southeastern Medical Oncology Center-Goldsboro
🇺🇸
Goldsboro, North Carolina, United States
Good Samaritan Hospital - Cincinnati
🇺🇸
Cincinnati, Ohio, United States
Dayton Physicians LLC-Miami Valley South
🇺🇸
Centerville, Ohio, United States
Blanchard Valley Hospital
🇺🇸
Findlay, Ohio, United States
Orion Cancer Care
🇺🇸
Findlay, Ohio, United States
Springfield Regional Medical Center
🇺🇸
Springfield, Ohio, United States
Saint Alphonsus Medical Center-Ontario
🇺🇸
Ontario, Oregon, United States
First Dayton Cancer Care
🇺🇸
Kettering, Ohio, United States
Upper Valley Medical Center
🇺🇸
Troy, Ohio, United States
Memorial Hospital
🇺🇸
Chattanooga, Tennessee, United States
Memorial GYN Plus
🇺🇸
Ooltewah, Tennessee, United States
Harrison Medical Center
🇺🇸
Bremerton, Washington, United States
Sovah Health Martinsville
🇺🇸
Martinsville, Virginia, United States
WVUH-Berkely Medical Center
🇺🇸
Martinsburg, West Virginia, United States
Camden Clark Medical Center
🇺🇸
Parkersburg, West Virginia, United States
United Hospital Center
🇺🇸
Bridgeport, West Virginia, United States
Marshfield Medical Center-River Region at Stevens Point
🇺🇸
Stevens Point, Wisconsin, United States
Marshfield Clinic-Chippewa Center
🇺🇸
Chippewa Falls, Wisconsin, United States
Marshfield Clinic-Minocqua Center
🇺🇸
Minocqua, Wisconsin, United States
Marshfield Medical Center-Marshfield
🇺🇸
Marshfield, Wisconsin, United States
Marshfield Clinic - Wisconsin Rapids Center
🇺🇸
Wisconsin Rapids, Wisconsin, United States
Great Lakes Cancer Management Specialists-Van Elslander Cancer Center
🇺🇸
Grosse Pointe Woods, Michigan, United States
Eden Hospital Medical Center
🇺🇸
Castro Valley, California, United States
Sanford Joe Lueken Cancer Center
🇺🇸
Bemidji, Minnesota, United States
Sutter Cancer Centers Radiation Oncology Services-Cameron Park
🇺🇸
Cameron Park, California, United States
Genesee Cancer and Blood Disease Treatment Center
🇺🇸
Flint, Michigan, United States
Saint Clare Hospital
🇺🇸
Lakewood, Washington, United States
Southeast Cancer Center
🇺🇸
Cape Girardeau, Missouri, United States
Sutter Cancer Research Consortium
🇺🇸
Novato, California, United States
North Memorial Medical Health Center
🇺🇸
Robbinsdale, Minnesota, United States
Delbert Day Cancer Institute at PCRMC
🇺🇸
Rolla, Missouri, United States
Great Lakes Cancer Management Specialists-Macomb Professional Building
🇺🇸
Warren, Michigan, United States
Academic Hematology Oncology Specialists
🇺🇸
Grosse Pointe Woods, Michigan, United States
Regions Hospital
🇺🇸
Saint Paul, Minnesota, United States
Freeman Health System
🇺🇸
Joplin, Missouri, United States
Missouri Baptist Medical Center
🇺🇸
Saint Louis, Missouri, United States
Ridgeview Medical Center
🇺🇸
Waconia, Minnesota, United States
Saint Louis Cancer and Breast Institute-South City
🇺🇸
Saint Louis, Missouri, United States
Mercy Hospital Washington
🇺🇸
Washington, Missouri, United States
Sutter Medical Center Sacramento
🇺🇸
Sacramento, California, United States
University of Colorado Hospital
🇺🇸
Aurora, Colorado, United States
Porter Adventist Hospital
🇺🇸
Denver, Colorado, United States
Saint Joseph Mercy Hospital
🇺🇸
Ann Arbor, Michigan, United States
University of Michigan Comprehensive Cancer Center
🇺🇸
Ann Arbor, Michigan, United States
Mayo Clinic in Rochester
🇺🇸
Rochester, Minnesota, United States
Alegent Health Immanuel Medical Center
🇺🇸
Omaha, Nebraska, United States
Hematology and Oncology Consultants PC
🇺🇸
Omaha, Nebraska, United States
Alegent Health Bergan Mercy Medical Center
🇺🇸
Omaha, Nebraska, United States
Alegent Health Lakeside Hospital
🇺🇸
Omaha, Nebraska, United States
Creighton University Medical Center
🇺🇸
Omaha, Nebraska, United States
Medical College of Wisconsin
🇺🇸
Milwaukee, Wisconsin, United States
Island Urology
🇺🇸
Honolulu, Hawaii, United States
Queen's Cancer Cenrer - POB I
🇺🇸
Honolulu, Hawaii, United States
Queen's Medical Center
🇺🇸
Honolulu, Hawaii, United States
Straub Clinic and Hospital
🇺🇸
Honolulu, Hawaii, United States
University of Hawaii Cancer Center
🇺🇸
Honolulu, Hawaii, United States
Hawaii Cancer Care Inc-Liliha
🇺🇸
Honolulu, Hawaii, United States
Queen's Cancer Center - Kuakini
🇺🇸
Honolulu, Hawaii, United States
The Cancer Center of Hawaii-Liliha
🇺🇸
Honolulu, Hawaii, United States
Jewish Hospital
🇺🇸
Louisville, Kentucky, United States
Hawaii Cancer Care Inc - Waterfront Plaza
🇺🇸
Honolulu, Hawaii, United States
Kuakini Medical Center
🇺🇸
Honolulu, Hawaii, United States
Kapiolani Medical Center for Women and Children
🇺🇸
Honolulu, Hawaii, United States
Saints Mary and Elizabeth Hospital
🇺🇸
Louisville, Kentucky, United States
UofL Health Medical Center Northeast
🇺🇸
Louisville, Kentucky, United States
Montefiore Medical Center-Einstein Campus
🇺🇸
Bronx, New York, United States
Montefiore Medical Center-Weiler Hospital
🇺🇸
Bronx, New York, United States
Montefiore Medical Center - Moses Campus
🇺🇸
Bronx, New York, United States
Mercy Medical Center - Des Moines
🇺🇸
Des Moines, Iowa, United States
Mission Cancer and Blood - Laurel
🇺🇸
Des Moines, Iowa, United States
Saint Joseph Radiation Oncology Resource Center
🇺🇸
Lexington, Kentucky, United States
Saint Joseph Hospital East
🇺🇸
Lexington, Kentucky, United States
Jewish Hospital Medical Center South
🇺🇸
Shepherdsville, Kentucky, United States
Marshfield Clinic - Ladysmith Center
🇺🇸
Ladysmith, Wisconsin, United States