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NCT05327686PHASE2Recruiting

Testing the Addition of Stereotactic Radiation Therapy With Immune Therapy for the Treatment of Patients With Unresectable or Metastatic Renal Cell Cancer, SAMURAI Trial

NRG Oncology

Start Date

2/1/2023

Completion Date

6/15/2028

Summary

This phase II trial tests whether the addition of radiation to the primary tumor, typically given with stereotactic ablative radiation therapy (SABR), in combination with standard of care immunotherapy improves outcomes in patients with renal cell cancer that is not recommended for surgery and has spread from where it first started (primary site) to other places in the body (metastatic). Radiation therapy uses high energy photons to kill tumor cells and shrink tumors. Stereotactic body radiation therapy uses special equipment to position a patient and deliver radiation to tumors with high precision. This method may kill tumor cells with fewer doses of radiation over a shorter period and cause less damage to normal tissue. Immunotherapy with monoclonal antibodies, such as nivolumab, ipilimumab, avelumab, and pembrolizumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Axitinib, cabozantinib, and lenvatinib are in a class of medications called antiangiogenic agents. They work by stopping the formation of blood vessels that bring oxygen and nutrients to tumor. This may slow the growth and spread of tumor. Giving SABR in combination with standard of care immunotherapy may help shrink or stabilize the cancer in patients with renal cell cancer.

Detailed Description

PRIMARY OBJECTIVE: I. To determine whether the addition of stereotactic ablative radiotherapy (SABR) to the primary tumor in combination with immunotherapy improves outcomes compared to immunotherapy alone in patients with metastatic, unresected, renal cell carcinoma (RCC). The primary endpoint is nephrectomy and radiographic progression-free survival (nrPFS) with progression determined as per iRECIST criteria. SECONDARY OBJECTIVES: I. To assess the safety, toxicity and tolerability of the two treatment strategies as defined by Common Terminology Criteria for Adverse Events (CTCAE) version 5 in each treatment arm. II. To assess the objective response rate (ORR) by Immune-related Response Evaluation Criteria in Solid Tumors (iRECIST) in each treatment arm. III. Nephrectomy and radiographic progression-free survival excluding nephrectomies that were performed for non-protocol specified indications (nephrectomy and radiographic progression-free survival \[nrPFS\]2). IV. Radiographic progression-free survival (rPFS). V. To assess overall survival (OS) in each treatment arm. VI. To assess the time to subsequent second-line therapy or death in each treatment arm. VII. To assess the rate of cytoreductive nephrectomy in each treatment arm. VIII. To assess treatment-free survival in patients who discontinue therapy for reason other than radiographic disease progression. IX. To assess the ORR by Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 and iRECIST in the primary renal mass. EXPLORATORY OBJECTIVES: I. To assess composite nrPFS in the predefined histological subgroups below: Ia. Clear cell versus non-clear cell histology; Ib. International Metastatic RCC database consortium (IMDC) intermediate versus poor risk group; Ic. Systemic treatment with immunotherapy-immunotherapy combination versus immunotherapy-vascular endothelial growth factor (VEGF) targeted therapy combination; Id. Sarcomatoid versus non sarcomatoid variant. II. To identify prognostic and predictive biomarkers of response to SABR in the context of immunotherapy based treatment via assessment of tissue and blood based biomarkers. III. To evaluate the abscopal effect of SABR with systemic therapy. IIIa. Compare ORR in non-irradiated target lesions in the control arm patients undergoing immunotherapy alone to the experimental arm undergoing SABR + immunotherapy. IV. To evaluate the impact of treatment on level of inferior vena cava (IVC) thrombus. V. To compare accruing center identified iRECIST progression and centrally identified iRECIST progression events on computed tomography (CT). OUTLINE: Patients are randomized to 1 of 2 arms. ARM I: Patients receive one of the following immunotherapy regimens per physician discretion: nivolumab intravenously (IV) over 30 minutes and ipilimumab IV over 30 minutes every 3 weeks for 4 doses followed by nivolumab IV over 30 minutes every 2 or 4 weeks; pembrolizumab IV over 30 minutes every 3 or 6 weeks and axitinib orally (PO) twice daily (BID); avelumab IV over 60 minutes every 2 weeks and axitinib PO BID; nivolumab IV over 30 minutes every 2 or 4 weeks and cabozantinib PO once daily (QD); OR pembrolizumab IV over 30 minutes every 3 or 6 weeks and lenvatinib PO QD. Treatment with immunotherapy continues in the absence of disease progression or unacceptable toxicity. Patients also undergo computed tomography (CT) scan or magnetic resonance imaging (MRI) throughout the trial. Patients may also undergo a bone scan as clinically indicated and blood sample collection throughout the trial. ARM II: Patients undergo SABR on 3 different days over 1-3 weeks and receive immunotherapy as in Arm I. Patients also undergo CT scan or MRI throughout the trial. Patients may also undergo a bone scan as clinically indicated and blood sample collection throughout the trial. After completion of study treatment, patients are followed up every 6 months for 5 years, and then annually for 3 years.

Eligibility Criteria

Age Range: 18 years to No maximum

Inclusion Criteria: * Pathologically (histologically or cytologically) proven diagnosis of renal cell carcinoma prior to registration * Node-positive unresectable (TxN1Mx) or metastatic (TxNxM1) based on the following diagnostic workup: * History/physical examination within 45 days prior to registration * CT/magnetic resonance imaging (MRI) of the chest/abdomen/pelvis within 45 days prior to registration * Patients must have IMDC intermediate (1-2 factors) or poor risk disease (\>= 3 factors) * Patients with a prior or concurrent malignancy whose natural history or treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational regimen are eligible for this trial * Patients with measurable disease (node positive or metastatic) as defined by RECIST version 1.1 excluding the primary renal tumor * Patient not recommended for or refused immediate cytoreductive nephrectomy * Candidate for standard of care therapy with either immuno-oncology (IO)-IO or IO-VEGF combination regimen * Primary renal tumor measuring 20 cm or less in anterior to posterior dimension only on axial imaging * Age \>= 18 * Karnofsky performance status \>= 60 within 45 days prior to registration * Hemoglobin \>= 8 g/dL (transfusions are allowed) (within 45 days prior to registration) * Platelet count \>= 50,000/mm\^3 (within 45 days prior to registration) * Absolute neutrophil count (ANC) \>= 1500/mm\^3 (within 45 days prior to registration) * Calculated (Calc.) creatinine clearance \>= 30 mL/min (within 45 days prior to registration) * Creatinine clearance (CrCl) \>= 30 mL/min estimated by Cockcroft-Gault Equation * For African American patients specifically whose renal function is not considered adequate by the formula above, an alternative formula that takes race into account (Chronic Kidney Disease Epidemiology Collaboration CKD-EPI formula) should be used for calculating the related estimated glomerular filtration rate (GFR) with a correction factor for African American race creatinine clearance for trial eligibility, where GFR \>= 30 mL/min/1.73m\^2 will be considered adequate * Total bilirubin =\< 1.5 x upper limit of normal (ULN) (except subjects with Gilbert Syndrome, who can have total bilirubin \< 3.0 mg/dL) (within 45 days prior to registration) * Aspartate aminotransferase and alanine aminotransferase (AST and ALT) =\< 3 x upper limit of normal (ULN) or \< 5 x ULN if hepatic metastases present (within 45 days prior to registration) * Patients with known human immunodeficiency virus (HIV) on effective anti-retroviral therapy with undetectable viral load within 6 months are eligible for this trial. Testing is not required for entry into protocol * For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated * Patients with a history of hepatitis C virus (HCV) infection must have been treated and cured. Patients with HCV infection who are currently on treatment are eligible if they have an undetectable HCV viral load * The patient must agree to use a highly effective contraception, including men with vasectomies if they are having sex with a woman of childbearing potential or with a woman who is pregnant, while on study drug and for 6 months following the last dose of study drug. Childbearing potential is defined as any person who has experienced menarche and who has not undergone surgical sterilization (hysterectomy or bilateral oophorectomy) or who is not postmenopausal * The patient or a legally authorized representative must provide study-specific informed consent prior to study entry and, for patients treated in the United States (U.S.), authorization permitting release of personal health information Exclusion Criteria: * Patients with planned treatment of all metastatic disease with definitive therapy including either surgery, ablative (non-palliative) doses of radiation, or intervention of some type (definitive interventional radiology techniques) to ALL metastatic sites rendering the patient without extra-renal measurable disease. Patients NOT planned for definitive treatment of all metastatic sites are eligible. Lesions radiated palliatively are not eligible for response assessment * Patients with untreated or unstable brain metastases or cranial epidural disease * Note: Patients who have been adequately treated with radiotherapy, radiosurgery, or surgery and stable for at least 4 weeks prior to registration as documented by MRI or CT imaging or deemed stable by clinical investigator are eligible. Treated brain metastases are defined as having no ongoing requirement for steroids and no evidence of progression or hemorrhage after treatment for at least 4 weeks prior to registration as documented by MRI or CT imaging or deemed stable by clinical investigator * Prior radiotherapy to the kidney that would result in overlap of radiation therapy fields treatment of the primary tumor * Any systemic therapy for metastatic renal cell carcinoma (RCC) that was initiated \> 90 days before registration, note that prior chemotherapy for a different cancer is allowed (completed \> 3 years prior to registration) * Severe, active comorbidity defined as follows: * Active autoimmune disease requiring ongoing therapy including systemic treatment with corticosteroids (\> 10 mg daily prednisone equivalents) or other immunosuppressive medications daily. Inhaled steroids and adrenal replacement steroid doses \> 10 mg daily prednisone equivalents are permitted in the absence of active autoimmune disease * History of severe allergic, anaphylactic or other hypersensitivity reactions to chimeric or humanized antibodies * Active tuberculosis (purified protein derivative \[PPD\] response without active tuberculosis \[TB\] is allowed) * Uncontrolled hypertension (systolic blood pressure \[BP\] \>= 190 mmHg or diastolic BP \> 110 mmHg) * Major surgery requiring hospital admission =\< 28 days prior to registration * Any serious (requiring hospital stay or long term rehab) non-healing wound, ulcer, or bone fracture within 45 days prior to registration * Any arterial thrombotic (ST elevation myocardial infarction \[STEMI\], non-ST elevation myocardial infarction \[NSTEMI\], cerebrovascular accident \[CVA\], etc) events within 180 days prior to registration * Active New York (NY) Heart Association class 3-4 heart failure symptoms * Moderate or severe hepatic impairment (Child-Pugh B or C) * Any history of untreated pulmonary embolism or deep venous thrombosis (DVT) within 180 days prior to registration. (Any asymptomatic or treated pulmonary embolism or asymptomatic treated deep venous thrombosis \> 30 days prior to registration is allowed) * Unstable cardiac arrhythmia within 180 days prior to registration * History of abdominal fistula, gastrointestinal perforation, intra-abdominal abscess, bowel obstruction, or gastric outlet obstruction within 180 days prior to registration * History of or active inflammatory bowel disease * Malabsorption syndrome within 45 days prior to registration * Pregnancy and individuals unwilling to discontinue nursing. For women of child bearing potential must have a negative pregnancy test =\< 45 days prior to registration

Interventions

BIOLOGICAL

Avelumab

DRUG

Axitinib

PROCEDURE

Biospecimen Collection

PROCEDURE

Bone Scan

DRUG

Cabozantinib

PROCEDURE

Computed Tomography

BIOLOGICAL

Ipilimumab

DRUG

Lenvatinib

PROCEDURE

Magnetic Resonance Imaging

BIOLOGICAL

Nivolumab

BIOLOGICAL

Pembrolizumab

RADIATION

Stereotactic Ablative Radiotherapy

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Conditions

Metastatic Renal Cell CarcinomaStage III Renal Cell Cancer AJCC v8Stage IV Renal Cell Cancer AJCC v8Unresectable Renal Cell Carcinoma

Locations

University of Alabama at Birmingham Cancer Center

Birmingham, Alabama 35233

United States

Kingman Regional Medical Center

Kingman, Arizona 86401

United States

Mayo Clinic Hospital in Arizona

Phoenix, Arizona 85054

United States

University of Arkansas for Medical Sciences

Little Rock, Arkansas 72205

United States

PCR Oncology

Arroyo Grande, California 93420

United States

Tower Cancer Research Foundation

Beverly Hills, California 90211

United States

Mills-Peninsula Medical Center

Burlingame, California 94010

United States

City of Hope Comprehensive Cancer Center

Duarte, California 91010

United States

UC San Diego Health System - Encinitas

Encinitas, California 92024

United States

UCI Health - Chao Family Comprehensive Cancer Center and Ambulatory Care

Irvine, California 92612

United States

UC San Diego Moores Cancer Center

La Jolla, California 92093

United States

Los Angeles General Medical Center

Los Angeles, California 90033

United States

USC / Norris Comprehensive Cancer Center

Los Angeles, California 90033

United States

Cedars-Sinai Medical Center

Los Angeles, California 90048

United States

Memorial Medical Center

Modesto, California 95355

United States

UC Irvine Health/Chao Family Comprehensive Cancer Center

Orange, California 92868

United States

Sutter Cancer Centers Radiation Oncology Services-Roseville

Roseville, California 95661

United States

Sutter Roseville Medical Center

Roseville, California 95661

United States

Sutter Medical Center Sacramento

Sacramento, California 95816

United States

UC San Diego Medical Center - Hillcrest

San Diego, California 92103

United States

UCSF Medical Center-Mission Bay

San Francisco, California 94158

United States

Pacific Central Coast Health Center-San Luis Obispo

San Luis Obispo, California 93401

United States

Mills Health Center

San Mateo, California 94401

United States

Ridley-Tree Cancer Center

Santa Barbara, California 93105

United States

Sutter Pacific Medical Foundation

Santa Rosa, California 95403

United States

UCHealth University of Colorado Hospital

Aurora, Colorado 80045

United States

UCHealth - Cherry Creek

Denver, Colorado 80206

United States

Poudre Valley Hospital

Fort Collins, Colorado 80524

United States

Cancer Care and Hematology-Fort Collins

Fort Collins, Colorado 80528

United States

UCHealth Greeley Hospital

Greeley, Colorado 80631

United States

UCHealth Highlands Ranch Hospital

Highlands Ranch, Colorado 80129

United States

UCHealth Lone Tree Health Center

Lone Tree, Colorado 80124

United States

Medical Center of the Rockies

Loveland, Colorado 80538

United States

Beebe Medical Center

Lewes, Delaware 19958

United States

Beebe South Coastal Health Campus

Millville, Delaware 19967

United States

Helen F Graham Cancer Center

Newark, Delaware 19713

United States

Medical Oncology Hematology Consultants PA

Newark, Delaware 19713

United States

Christiana Care Health System-Christiana Hospital

Newark, Delaware 19718

United States

Beebe Health Campus

Rehoboth Beach, Delaware 19971

United States

Christiana Care Health System-Wilmington Hospital

Wilmington, Delaware 19801

United States

Mount Sinai Comprehensive Cancer Center at Aventura

Aventura, Florida 33180

United States

Memorial Regional Hospital/Joe DiMaggio Children's Hospital

Hollywood, Florida 33021

United States

Mayo Clinic in Florida

Jacksonville, Florida 32224-9980

United States

Miami Cancer Institute

Miami, Florida 33176

United States

Mount Sinai Medical Center

Miami Beach, Florida 33140

United States

Memorial Hospital West

Pembroke Pines, Florida 33028

United States

Saint Alphonsus Cancer Care Center-Boise

Boise, Idaho 83706

United States

Saint Alphonsus Cancer Care Center-Caldwell

Caldwell, Idaho 83605

United States

Saint Alphonsus Cancer Care Center-Nampa

Nampa, Idaho 83687

United States

Alton Memorial Hospital

Alton, Illinois 62002

United States

Centralia Oncology Clinic

Centralia, Illinois 62801

United States

Northwestern University

Chicago, Illinois 60611

United States

University of Chicago Comprehensive Cancer Center

Chicago, Illinois 60637

United States

Carle at The Riverfront

Danville, Illinois 61832

United States

Cancer Care Specialists of Illinois - Decatur

Decatur, Illinois 62526

United States

Decatur Memorial Hospital

Decatur, Illinois 62526

United States

Northwestern Medicine Cancer Center Kishwaukee

DeKalb, Illinois 60115

United States

Carle Physician Group-Effingham

Effingham, Illinois 62401

United States

Crossroads Cancer Center

Effingham, Illinois 62401

United States

Northwestern Medicine Cancer Center Delnor

Geneva, Illinois 60134

United States

Northwestern Medicine Glenview Outpatient Center

Glenview, Illinois 60026

United States

Northwestern Medicine Grayslake Outpatient Center

Grayslake, Illinois 60030

United States

Ingalls Memorial Hospital

Harvey, Illinois 60426

United States

Northwestern Medicine Lake Forest Hospital

Lake Forest, Illinois 60045

United States

Carle Physician Group-Mattoon/Charleston

Mattoon, Illinois 61938

United States

UC Comprehensive Cancer Center at Silver Cross

New Lenox, Illinois 60451

United States

Cancer Care Center of O'Fallon

O'Fallon, Illinois 62269

United States

HSHS Saint Elizabeth's Hospital

O'Fallon, Illinois 62269

United States

Northwestern Medicine Oak Brook

Oak Brook, Illinois 60523

United States

Northwestern Medicine Orland Park

Orland Park, Illinois 60462

United States

University of Chicago Medicine-Orland Park

Orland Park, Illinois 60462

United States

UW Health Carbone Cancer Center Rockford

Rockford, Illinois 61114

United States

Memorial Hospital East

Shiloh, Illinois 62269

United States

Southern Illinois University School of Medicine

Springfield, Illinois 62702

United States

Springfield Clinic

Springfield, Illinois 62702

United States

Springfield Memorial Hospital

Springfield, Illinois 62781

United States

Carle Cancer Center

Urbana, Illinois 61801

United States

The Carle Foundation Hospital

Urbana, Illinois 61801

United States

Northwestern Medicine Cancer Center Warrenville

Warrenville, Illinois 60555

United States

UChicago Medicine Northwest Indiana

Crown Point, Indiana 46307

United States

Franciscan Health Indianapolis

Indianapolis, Indiana 46237

United States

Franciscan Health Mooresville

Mooresville, Indiana 46158

United States

Mary Greeley Medical Center

Ames, Iowa 50010

United States

McFarland Clinic - Ames

Ames, Iowa 50010

United States

UI Health Care Mission Cancer and Blood - Ankeny Clinic

Ankeny, Iowa 50023

United States

UI Health Care Mission Cancer and Blood - West Des Moines Clinic

Clive, Iowa 50325

United States

Iowa Methodist Medical Center

Des Moines, Iowa 50309

United States

UI Health Care Mission Cancer and Blood - Des Moines Clinic

Des Moines, Iowa 50309

United States

UI Health Care Mission Cancer and Blood - Laurel Clinic

Des Moines, Iowa 50314

United States

UI Health Care Mission Cancer and Blood - Waukee Clinic

Waukee, Iowa 50263

United States

Louisiana Hematology Oncology Associates LLC

Baton Rouge, Louisiana 70809

United States

Mary Bird Perkins Cancer Center

Baton Rouge, Louisiana 70809

United States

Mary Bird Perkins Cancer Center - Metairie

Metairie, Louisiana 70002

United States

East Jefferson General Hospital

Metairie, Louisiana 70006

United States

LSU Healthcare Network / Metairie Multi-Specialty Clinic

Metairie, Louisiana 70006

United States

Louisiana State University Health Science Center

New Orleans, Louisiana 70112

United States

University Medical Center New Orleans

New Orleans, Louisiana 70112

United States

Touro Infirmary

New Orleans, Louisiana 70115

United States

MaineHealth Coastal Cancer Treatment Center

Bath, Maine 04530

United States

MaineHealth Maine Medical Center - Biddeford

Biddeford, Maine 04005

United States

MaineHealth Maine Medical Center - Portland

Portland, Maine 04102

United States

MaineHealth Cancer Care and IV Therapy - Sanford

Sanford, Maine 04073

United States

MaineHealth Cancer Care Center of York County

Sanford, Maine 04073

United States

MaineHealth Maine Medical Center- Scarborough

Scarborough, Maine 04074

United States

MaineHealth Cancer Care and IV Therapy - South Portland

South Portland, Maine 04106

United States

University of Maryland/Greenebaum Cancer Center

Baltimore, Maryland 21201

United States

Central Maryland Radiation Oncology in Howard County

Columbia, Maryland 21044

United States

UM Baltimore Washington Medical Center/Tate Cancer Center

Glen Burnie, Maryland 21061

United States

Beverly Hospital

Beverly, Massachusetts 01915

United States

Massachusetts General Hospital Cancer Center

Boston, Massachusetts 02114

United States

Brigham and Women's Hospital

Boston, Massachusetts 02115

United States

Dana-Farber Cancer Institute

Boston, Massachusetts 02215

United States

Lahey Hospital and Medical Center

Burlington, Massachusetts 01805

United States

Addison Gilbert Hospital

Gloucester, Massachusetts 01930

United States

Lahey Clinic Peabody

Peabody, Massachusetts 01960

United States

Beth Israel Deaconess Medical Center/Winchester Center for Cancer Care

Winchester, Massachusetts 01890

United States

Trinity Health Saint Joseph Mercy Hospital Ann Arbor

Ann Arbor, Michigan 48106

United States

University of Michigan Rogel Cancer Center

Ann Arbor, Michigan 48109

United States

Trinity Health IHA Medical Group Hematology Oncology - Brighton

Brighton, Michigan 48114

United States

Trinity Health Medical Center - Brighton

Brighton, Michigan 48114

United States

Trinity Health IHA Medical Group Hematology Oncology - Canton

Canton, Michigan 48188

United States

Trinity Health Medical Center - Canton

Canton, Michigan 48188

United States

Chelsea Hospital

Chelsea, Michigan 48118

United States

Trinity Health IHA Medical Group Hematology Oncology - Chelsea Hospital

Chelsea, Michigan 48118

United States

Corewell Health Dearborn Hospital

Dearborn, Michigan 48124

United States

Corewell Health Farmington Hills Hospital

Farmington Hills, Michigan 48336

United States

University of Michigan Health - Sparrow Lansing

Lansing, Michigan 48912

United States

Trinity Health Saint Mary Mercy Livonia Hospital

Livonia, Michigan 48154

United States

Corewell Health William Beaumont University Hospital

Royal Oak, Michigan 48073

United States

Corewell Health Beaumont Troy Hospital

Troy, Michigan 48085

United States

Trinity Health IHA Medical Group Hematology Oncology Ann Arbor Campus

Ypsilanti, Michigan 48197

United States

Sanford Joe Lueken Cancer Center

Bemidji, Minnesota 56601

United States

Essentia Health Saint Joseph's Medical Center

Brainerd, Minnesota 56401

United States

Minnesota Oncology Hematology PA-Chaska

Chaska, Minnesota 55318

United States

Essentia Health - Deer River Clinic

Deer River, Minnesota 56636

United States

Essentia Health Cancer Center

Duluth, Minnesota 55805

United States

Essentia Health Saint Mary's Medical Center

Duluth, Minnesota 55805

United States

Miller-Dwan Hospital

Duluth, Minnesota 55805

United States

Fairview Southdale Hospital

Edina, Minnesota 55435

United States

Essentia Health Hibbing Clinic

Hibbing, Minnesota 55746

United States

Fairview Clinics and Surgery Center Maple Grove

Maple Grove, Minnesota 55369

United States

Abbott-Northwestern Hospital

Minneapolis, Minnesota 55407

United States

Hennepin County Medical Center

Minneapolis, Minnesota 55415

United States

University of Minnesota/Masonic Cancer Center

Minneapolis, Minnesota 55455

United States

Mayo Clinic in Rochester

Rochester, Minnesota 55905

United States

Regions Hospital

Saint Paul, Minnesota 55101

United States

Essentia Health Sandstone

Sandstone, Minnesota 55072

United States

Saint Francis Regional Medical Center

Shakopee, Minnesota 55379

United States

Lakeview Hospital

Stillwater, Minnesota 55082

United States

Essentia Health Virginia Clinic

Virginia, Minnesota 55792

United States

Ridgeview Medical Center

Waconia, Minnesota 55387

United States

Saint Francis Medical Center

Cape Girardeau, Missouri 63703

United States

Siteman Cancer Center at Saint Peters Hospital

City of Saint Peters, Missouri 63376

United States

MU Health - University Hospital/Ellis Fischel Cancer Center

Columbia, Missouri 65212

United States

Siteman Cancer Center at West County Hospital

Creve Coeur, Missouri 63141

United States

Mercy Hospital Springfield

Springfield, Missouri 65804

United States

Washington University School of Medicine

St Louis, Missouri 63110

United States

Mercy Hospital South

St Louis, Missouri 63128

United States

Siteman Cancer Center-South County

St Louis, Missouri 63129

United States

Siteman Cancer Center at Christian Hospital

St Louis, Missouri 63136

United States

Mercy Hospital Saint Louis

St Louis, Missouri 63141

United States

Nebraska Medicine-Bellevue

Bellevue, Nebraska 68123

United States

Nebraska Medicine-Village Pointe

Omaha, Nebraska 68118

United States

University of Nebraska Medical Center

Omaha, Nebraska 68198

United States

Memorial Sloan Kettering Basking Ridge

Basking Ridge, New Jersey 07920

United States

Cooper Hospital University Medical Center

Camden, New Jersey 08103

United States

Monmouth Medical Center Southern Campus

Lakewood, New Jersey 08701

United States

Monmouth Medical Center

Long Branch, New Jersey 07740

United States

Memorial Sloan Kettering Monmouth

Middletown, New Jersey 07748

United States

Memorial Sloan Kettering Bergen

Montvale, New Jersey 07645

United States

Cooper CyberKnife Center

Mount Laurel, New Jersey 08054

United States

Rutgers Cancer Institute of New Jersey

New Brunswick, New Jersey 08903

United States

Rutgers New Jersey Medical School

Newark, New Jersey 07101

United States

Community Medical Center

Toms River, New Jersey 08755

United States

Lovelace Medical Center-Saint Joseph Square

Albuquerque, New Mexico 87102

United States

Lovelace Radiation Oncology

Albuquerque, New Mexico 87109

United States

Northwell Health Imbert Cancer Center

Bay Shore, New York 11706

United States

Memorial Sloan Kettering Commack

Commack, New York 11725

United States

Glens Falls Hospital

Glens Falls, New York 12801

United States

Northwell Health Cancer Institute at Huntington

Greenlawn, New York 11740

United States

Memorial Sloan Kettering Westchester

Harrison, New York 10604

United States

Northwell Health/Center for Advanced Medicine

Lake Success, New York 11042

United States

Northern Westchester Hospital

Mount Kisco, New York 10549

United States

Laura and Isaac Perlmutter Cancer Center at NYU Langone

New York, New York 10016

United States

Manhattan Eye Ear and Throat Hospital

New York, New York 10065

United States

Memorial Sloan Kettering Cancer Center

New York, New York 10065

United States

Lenox Hill Hospital

New York, New York 10075

United States

Phelps Memorial Hospital Center

Sleepy Hollow, New York 10591

United States

Stony Brook University Medical Center

Stony Brook, New York 11794

United States

Memorial Sloan Kettering Nassau

Uniondale, New York 11553

United States

Duke Cancer Center Cary

Cary, North Carolina 27518

United States

UNC Lineberger Comprehensive Cancer Center

Chapel Hill, North Carolina 27599

United States

Carolinas Medical Center/Levine Cancer Institute

Charlotte, North Carolina 28203

United States

Atrium Health Pineville/LCI-Pineville

Charlotte, North Carolina 28210

United States

Atrium Health University City/LCI-University

Charlotte, North Carolina 28262

United States

Levine Cancer Institute-Ballantyne

Charlotte, North Carolina 28277

United States

Wake Forest University at Clemmons

Clemmons, North Carolina 27012

United States

Atrium Health Cabarrus/LCI-Concord

Concord, North Carolina 28025

United States

Duke University Medical Center

Durham, North Carolina 27710

United States

Levine Cancer Institute-Gaston

Gastonia, North Carolina 28054

United States

Hayworth Cancer Center

High Point, North Carolina 27262

United States

Atrium Health Union/LCI-Union

Monroe, North Carolina 28112

United States

Duke Cancer Center Raleigh

Raleigh, North Carolina 27609

United States

Wake Forest Baptist Health - Wilkes Medical Center

Wilkesboro, North Carolina 28659

United States

Wake Forest University Health Sciences

Winston-Salem, North Carolina 27157

United States

Sanford Bismarck Medical Center

Bismarck, North Dakota 58501

United States

Sanford Broadway Medical Center

Fargo, North Dakota 58122

United States

Sanford Roger Maris Cancer Center

Fargo, North Dakota 58122

United States

UH Seidman Cancer Center at UH Avon Health Center

Avon, Ohio 44011

United States

UHHS-Chagrin Highlands Medical Center

Beachwood, Ohio 44122

United States

Dayton Physicians LLC-Miami Valley South

Centerville, Ohio 45459

United States

Miami Valley Hospital South

Centerville, Ohio 45459

United States

University of Cincinnati Cancer Center-UC Medical Center

Cincinnati, Ohio 45219

United States

Case Western Reserve University

Cleveland, Ohio 44106

United States

Ohio State University Comprehensive Cancer Center

Columbus, Ohio 43210

United States

Miami Valley Hospital

Dayton, Ohio 45409

United States

Premier Blood and Cancer Center

Dayton, Ohio 45409

United States

Dayton Physician LLC - Englewood

Dayton, Ohio 45415

United States

Miami Valley Hospital North

Dayton, Ohio 45415

United States

Atrium Medical Center-Middletown Regional Hospital

Franklin, Ohio 45005-1066

United States

Dayton Physicians LLC-Atrium

Franklin, Ohio 45005

United States

Miami Valley Cancer Care and Infusion

Greenville, Ohio 45331

United States

UH Seidman Cancer Center at Lake Health Mentor Campus

Mentor, Ohio 44060

United States

University Hospitals Parma Medical Center

Parma, Ohio 44129

United States

University Hospitals Portage Medical Center

Ravenna, Ohio 44266

United States

Upper Valley Medical Center

Troy, Ohio 45373

United States

University of Cincinnati Cancer Center-West Chester

West Chester, Ohio 45069

United States

University of Oklahoma Health Sciences Center

Oklahoma City, Oklahoma 73104

United States

Oklahoma Cancer Specialists and Research Institute-Tulsa

Tulsa, Oklahoma 74146

United States

Lehigh Valley Hospital-Cedar Crest

Allentown, Pennsylvania 18103

United States

UPMC-Heritage Valley Health System Beaver

Beaver, Pennsylvania 15009

United States

Lehigh Valley Hospital - Muhlenberg

Bethlehem, Pennsylvania 18017

United States

Carlisle Regional Cancer Center

Carlisle, Pennsylvania 17015

United States

Christiana Care Health System-Concord Health Center

Chadds Ford, Pennsylvania 19317

United States

Geisinger Medical Center

Danville, Pennsylvania 17822

United States

UPMC Hillman Cancer Center Erie

Erie, Pennsylvania 16505

United States

Saint Vincent Hospital

Erie, Pennsylvania 16544

United States

UPMC Cancer Center at UPMC Horizon

Farrell, Pennsylvania 16121

United States

UPMC Cancer Centers - Arnold Palmer Pavilion

Greensburg, Pennsylvania 15601

United States

UPMC Pinnacle Cancer Center/Community Osteopathic Campus

Harrisburg, Pennsylvania 17109

United States

Geisinger Medical Center-Cancer Center Hazleton

Hazleton, Pennsylvania 18201

United States

Penn State Milton S Hershey Medical Center

Hershey, Pennsylvania 17033-0850

United States

IRMC Cancer Center

Indiana, Pennsylvania 15701

United States

Jefferson Hospital

Jefferson Hills, Pennsylvania 15025

United States

Geisinger Medical Oncology-Lewisburg

Lewisburg, Pennsylvania 17837

United States

UPMC Hillman Cancer Center at Rocco And Nancy Ortenzio Cancer Pavilion

Mechanicsburg, Pennsylvania 17050

United States

Forbes Hospital

Monroeville, Pennsylvania 15146

United States

UPMC Cancer Center - Monroeville

Monroeville, Pennsylvania 15146

United States

UPMC Hillman Cancer Center - Monroeville

Monroeville, Pennsylvania 15146

United States

UPMC Hillman Cancer Center - New Castle

New Castle, Pennsylvania 16105

United States

Allegheny General Hospital

Pittsburgh, Pennsylvania 15212

United States

UPMC-Magee Womens Hospital

Pittsburgh, Pennsylvania 15213

United States

UPMC-Saint Margaret

Pittsburgh, Pennsylvania 15215

United States

West Penn Hospital

Pittsburgh, Pennsylvania 15224

United States

University of Pittsburgh Cancer Institute (UPCI)

Pittsburgh, Pennsylvania 15232

United States

UPMC-Shadyside Hospital

Pittsburgh, Pennsylvania 15232

United States

UPMC-Passavant Hospital

Pittsburgh, Pennsylvania 15237

United States

UPMC-Saint Clair Hospital Cancer Center

Pittsburgh, Pennsylvania 15243

United States

Geisinger Cancer Services-Pottsville

Pottsville, Pennsylvania 17901

United States

Community Medical Center

Scranton, Pennsylvania 18510

United States

UPMC Cancer Center at UPMC Northwest

Seneca, Pennsylvania 16346

United States

UPMC Cancer Center-Washington

Washington, Pennsylvania 15301

United States

UPMC Washington Hospital Radiation Oncology

Washington, Pennsylvania 15301

United States

Reading Hospital

West Reading, Pennsylvania 19611

United States

Wexford Health and Wellness Pavilion

Wexford, Pennsylvania 15090

United States

Geisinger Wyoming Valley/Henry Cancer Center

Wilkes-Barre, Pennsylvania 18711

United States

Divine Providence Hospital

Williamsport, Pennsylvania 17754

United States

UPMC Memorial

York, Pennsylvania 17408

United States

Medical University of South Carolina

Charleston, South Carolina 29425

United States

Self Regional Healthcare

Greenwood, South Carolina 29646

United States

Sanford Cancer Center Oncology Clinic

Sioux Falls, South Dakota 57104

United States

Sanford USD Medical Center - Sioux Falls

Sioux Falls, South Dakota 57117-5134

United States

Parkland Memorial Hospital

Dallas, Texas 75235

United States

UT Southwestern Simmons Cancer Center - RedBird

Dallas, Texas 75237

United States

UT Southwestern/Simmons Cancer Center-Dallas

Dallas, Texas 75390

United States

UT Southwestern/Simmons Cancer Center-Fort Worth

Fort Worth, Texas 76104

United States

UT Southwestern Clinical Center at Richardson/Plano

Richardson, Texas 75080

United States

Scott and White Memorial Hospital

Temple, Texas 76508

United States

Central Vermont Medical Center/National Life Cancer Treatment

Berlin Corners, Vermont 05602

United States

University of Vermont Medical Center

Burlington, Vermont 05401

United States

University of Vermont and State Agricultural College

Burlington, Vermont 05405

United States

Inova Alexandria Hospital

Alexandria, Virginia 22304

United States

Inova Schar Cancer Institute

Fairfax, Virginia 22031

United States

Inova Fair Oaks Hospital

Fairfax, Virginia 22033

United States

Bon Secours Saint Francis Medical Center

Midlothian, Virginia 23114

United States

Bon Secours Cancer Institute at Reynolds Crossing

Richmond, Virginia 23230

United States

Virginia Mason Medical Center

Seattle, Washington 98101

United States

West Virginia University Charleston Division

Charleston, West Virginia 25304

United States

Edwards Comprehensive Cancer Center

Huntington, West Virginia 25701

United States

Langlade Hospital and Cancer Center

Antigo, Wisconsin 54409

United States

Duluth Clinic Ashland

Ashland, Wisconsin 54806

United States

Northwest Wisconsin Cancer Center

Ashland, Wisconsin 54806

United States

Marshfield Medical Center-EC Cancer Center

Eau Claire, Wisconsin 54701

United States

Saint Vincent Hospital Cancer Center Green Bay

Green Bay, Wisconsin 54301

United States

Saint Vincent Hospital Cancer Center at Saint Mary's

Green Bay, Wisconsin 54303

United States

Essentia Health-Hayward Clinic

Hayward, Wisconsin 54843

United States

Gundersen Lutheran Medical Center

La Crosse, Wisconsin 54601

United States

Marshfield Medical Center - Ladysmith

Ladysmith, Wisconsin 54848

United States

University of Wisconsin Carbone Cancer Center - Eastpark Medical Center

Madison, Wisconsin 53718

United States

University of Wisconsin Carbone Cancer Center - University Hospital

Madison, Wisconsin 53792

United States

Marshfield Medical Center-Marshfield

Marshfield, Wisconsin 54449

United States

Froedtert Menomonee Falls Hospital

Menomonee Falls, Wisconsin 53051

United States

Medical College of Wisconsin

Milwaukee, Wisconsin 53226

United States

Marshfield Medical Center - Minocqua

Minocqua, Wisconsin 54548

United States

ProHealth D N Greenwald Center

Mukwonago, Wisconsin 53149

United States

Marshfield Medical Center - Neillsville

Neillsville, Wisconsin 54456

United States

Cancer Center of Western Wisconsin

New Richmond, Wisconsin 54017

United States

Drexel Town Square Health Center

Oak Creek, Wisconsin 53154

United States

ProHealth Oconomowoc Memorial Hospital

Oconomowoc, Wisconsin 53066

United States

Aspirus Cancer Care - James Beck Cancer Center

Rhinelander, Wisconsin 54501

United States

Marshfield Medical Center-Rice Lake

Rice Lake, Wisconsin 54868

United States

Saint Vincent Hospital Cancer Center at Sheboygan

Sheboygan, Wisconsin 53081

United States

Essentia Health-Spooner Clinic

Spooner, Wisconsin 54801

United States

Aspirus Cancer Care - Stevens Point

Stevens Point, Wisconsin 54481

United States

Marshfield Medical Center-River Region at Stevens Point

Stevens Point, Wisconsin 54482

United States

Saint Vincent Hospital Cancer Center at Sturgeon Bay

Sturgeon Bay, Wisconsin 54235-1495

United States

Essentia Health Saint Mary's Hospital - Superior

Superior, Wisconsin 54880

United States

UW Cancer Center at ProHealth Care

Waukesha, Wisconsin 53188

United States

Aspirus Regional Cancer Center

Wausau, Wisconsin 54401

United States

Froedtert West Bend Hospital/Kraemer Cancer Center

West Bend, Wisconsin 53095

United States

Marshfield Medical Center - Weston

Weston, Wisconsin 54476

United States

Aspirus Cancer Care - Wisconsin Rapids

Wisconsin Rapids, Wisconsin 54494

United States

Marshfield Clinic - Wisconsin Rapids Center

Wisconsin Rapids, Wisconsin 54494

United States

Peter MacCallum Cancer Centre

Melbourne, Victoria 3000

Australia

University Health Network-Princess Margaret Hospital

Toronto, Ontario M5G 2M9

Canada

CHU de Quebec-L'Hotel-Dieu de Quebec (HDQ)

Québec, Quebec G1R 2J6

Canada

Beacon Hospital

Dublin, Co Dublin 18

Ireland

Saint Lukes Hospital

Dublin, Co Dublin 6

Ireland