Breast Cancer Clinical Trial
Clinical Trial of Neoadjuvant Chemotherapy With Atezolizumab or Placebo in Patients With Triple-Negative Breast Cancer Followed After Surgery by Atezolizumab or Placebo
Summary
The main purpose of this study is to learn if the usual chemotherapy given before surgery (neoadjuvant therapy) for breast cancer plus the experimental drug, atezolizumab, is better than the usual chemotherapy plus a placebo. (A placebo is a drug that looks like the study drug but contains no medication.) The usual chemotherapy in this study is paclitaxel (WP) and carboplatin followed by doxorubicin and cyclophosphamide (AC) or epirubicin and cyclophosphamide (EC). Usually, after neoadjuvant therapy and surgery for triple negative breast cancer, no additional treatment is given unless the cancer returns. This study will also look at continuing treatment after surgery with atezolizumab or the placebo. To be better, atezolizumab given with the neoadjuvant therapy should be better at: 1) decreasing the amount of tumor in the breast than the placebo given with the usual chemotherapy and 2) decreasing the chance of the cancer from returning after surgery.
Another purpose of this study is to test the good and bad effects of atezolizumab when added to the usual chemotherapy. Atezolizumab may keep your cancer from growing but it can also cause side effects.
Full Description
NSABP B-59/GBG 96-GeparDouze is a prospective, randomized, double-blind, Phase III clinical trial. This is a collaborative study being conducted by NSABP Foundation, Inc. in partnership with the German Breast Group (GBG), and supported by funding by Genentech, a Member of the Roche Group, and F. Hoffmann-La Roche, Ltd.
In this clinical trial of neoadjuvant and adjuvant administration of atezolizumab/placebo in patients with high risk triple-negative breast cancer, the potential incremental efficacy and safety of neoadjuvant administration of atezolizumab/placebo with a sequential regimen of weekly paclitaxel with every-3-week carboplatin followed immediately by neoadjuvant administration of atezolizumab/placebo with AC/EC will be evaluated. Patients will then undergo surgery. Following recovery from surgery, patients will initiate approximately 6 months of adjuvant therapy with atezolizumab/placebo and receive the same investigational agent they received pre-operatively. Administration of radiation therapy will be based on local standards at the discretion of patients and investigators, but if administered, atezolizumab/placebo will be administered concurrently. Adjuvant atezolizumab/placebo may be delayed until after completion of radiation therapy per investigator discretion. Patients with residual invasive cancer at the time of surgery may receive capecitabine concurrently with atezolizumab/placebo in the adjuvant setting per investigator discretion and local guidelines. Patients with germline BRCA1 or BRCA2 mutations with residual invasive cancer at the time of surgery may receive olaparib in the adjuvant setting per investigator discretion and local guidelines. Patients receiving olaparib must discontinue atezolizumab/placebo.
The primary aims of the study are 1) to determine value of atezolizumab in improving pathologic complete response in the breast and post-therapy lymph nodes evaluated histologically (pCR breast and nodes [(ypT0/Tis ypN0)]), and 2) to determine the value of atezolizumab in improving event-free survival (EFS). Secondary aims include: pathologic complete response in the breast (ypT0/Tis); pathologic complete response in the breast and lymph nodes (ypT0 ypN0); positive nodal status conversion rate; overall survival; recurrence-free interval: distant disease-free survival; brain metastases free survival; and toxicity. The stratification factors for the study are: 1) clinical size of the primary tumor (1.1-3.0 cm; > 3.0 cm); 2) nodal status as determined by protocol-specified criteria (negative, positive); 3) AC/EC (every 2 weeks; every 3 weeks); and 4) Region (North America; Europe).
For patient eligibility, local testing on the diagnostic core must have determined the patient's tumor to be ER-negative, PgR-negative, and HER2-negative by current ASCO/CAP guidelines. Material from either the diagnostic core biopsy or the research biopsy must be sent for central testing for confirmation of ER, PgR, and HER2 to confirm eligibility. If local testing has determined a tumor to be HER2 equivocal or to have a borderline ER/PgR status (% IHC staining < 10% for both), material may be submitted for central testing to determine eligibility.
In order to proactively identify and further assess any cardiac toxicity that may occur with the combination of anthracyclines and atezolizumab, this study includes a cardiac safety lead-in for the first 60 patients who initiate AC/EC. The safety lead-in will consist of assessment of ECG and serum troponin-T obtained just prior to administration of the first dose of AC/EC, following completion of the administration of the 1st and 3rd cycle of AC/EC prior to initiation of the atezolizumab/placebo. An additional assessment of LVEF with echocardiogram or MUGA scan will also be obtained prior to the 3rd dose of AC/EC. In order to provide an early assessment of cardiac safety, results of the troponin-T assessments, ECGs, LVEF assessment, and cardiac safety data will be evaluated by the Data Safety Monitoring Board (DSMB) when the last of the initial 20 patients who initiate AC/EC undergo their scheduled post-surgery LVEF assessment. When the last of the first 60 patients to initiate AC/EC undergo their scheduled post-surgery LVEF assessment, results of the troponin assessments, ECGs, LVEF assessments, and cardiac safety data from all 60 patients will be evaluated by the DSMB.
Research core biopsies of breast primary at baseline and 1-4 days prior to the second dose of atezolizumab/placebo are a study requirement for all patients. One to three representative blocks of residual primary tumor containing the maximum amount of tumor and node with the largest focus of metastasis is required from the definitive breast surgery if gross residual disease is greater than or equal to 1.0 cm. If gross residual disease is less than 1.0 cm, tissue should be submitted, if possible. Blood specimens will be collected on all patients at baseline for exploratory biomarker analysis and to support future correlative studies.
Accrual to NSABP B-59/GBG 96-GeparDouze began in December 2017 and was completed in May 2021 with a total of 1550 patients randomized. Based on actual accrual and the decision to eliminate pCR as a co-primary endpoint, we recalculated the power to detect a hazard ratio of 0.70 attributed to the addition of atezolizumab, assuming a lost-to-follow-up rate of 0.00083 per month, using the actual accrual pattern for the power calculation. With 1550 patients accrued in 42 months, an additional 22 months follow up will allow us to obtain 252 events under the assumptions stated above, which will provide 80% power to detect a HR of 0.7 between the atezolizumab and the placebo arm at an overall 2-sided alpha level of 0.05.
Eligibility Criteria
Inclusion Criteria:
The patient must have consented to participate and, prior to beginning specific study procedures, must have signed and dated an appropriate IRB-approved consent form that conforms to federal and institutional guidelines for study treatment and for submission of tumor samples from a research biospy as required by NSABP B-59/GBG 96-GeparDouze for baseline correlative science studies.
The diagnosis of invasive adenocarcinoma of the breast must have been made by core needle biopsy.
Local testing on the diagnostic core must have determined the tumor to be ER-negative, PgR-negative, and HER2-negative by current ASCO/CAP guidelines. (If local testing has determined a tumor to be HER2 equivocal or to have a borderline ER/PgR status (% IHC staining < 10% for both) and other eligibility criteria are met, material may be submitted for central testing to determine eligibility.)
Central testing for ER, PgR, and HER2 will be performed, and the tumor must be determined to be ER-negative, PgR-negative, and HER2-negative by current ASCO/CAP Guidelines Recommendations.
The tumor specimen used for central ER, PgR, and HER2 testing must also be used for central testing of PD-L1 status using the Ventana PD-L1 testing result including PD-L1 indeterminate Patients will be classifies as positive, negative, or indeterminate for stratification purposes.
Patients must be ≥ 18 years old.
Patient may be female or male.
The ECOG performance status must be 0-1.
The primary tumor can be clinical stage T2 or T3, if clinically node negative according to AJCC 7th Edition. If the regional lymph nodes are cN1 and cytologically or histologically positive or cN2-N3 with or without a biopsy, the primary breast tumor can be clinically T1c, T2, or T3.
Ipsilateral axillary lymph nodes must be evaluated by imaging (mammogram, ultrasound, and/or MRI) within 84 days prior to study entry. If suspicious or abnormal, FNA or core biopsy is recommended. Findings of these evaluations will be used to define the nodal status prior to study entry according to the following criteria:
Nodal status - negative (Imaging of the axilla is negative; Imaging is suspicious or abnormal but the FNA or core biopsy of the questionable node[s] on imaging is negative)
Nodal status - positive (FNA or core biopsy of the node[s] is cytologically or histologically suspicious or positive; Imaging is suspicious or abnormal but FNA or core biopsy was not performed.)
Patients with synchronous bilateral or multicentric HER2-negative breast cancer are eligible as long as the highest risk tumor is ER-negative and PgR-negative and meets stage eligibility criteria. All of the other invasive tumors must also be HER2-negative by ASCO/CAP Guidelines based on local testing. Central testing to confirm TNBC status is only required for the highest risk tumor.
Blood counts performed within 28 days prior to randomization must meet the following criteria:
ANC must be ≥ 1500/mm3;
platelet count must be ≥ 100,000/mm3; and
hemoglobin must be ≥10 g/dL.
The following criteria for evidence of adequate hepatic function performed within 28 days prior to randomization must be met:
total bilirubin must be ≤ ULN for the lab unless the patient has a bilirubin elevation > ULN to 1.5 x ULN due to Gilbert's disease or similar syndrome involving slow conjugation of bilirubin; and
alkaline phosphatase must be ≤ 2.5 x ULN for the lab; and
AST and ALT must be ≤ 1.5 x ULN for the lab.
Patients with AST or ALT or alkaline phosphatase > ULN are eligible for inclusion in the study if liver imaging (CT, MRI, abdominal ultrasound, PET-CT, or PET scan) performed within 28 days prior to randomization does not demonstrate metastatic disease and the requirements in criterion (just above) are met.
Patients with alkaline phosphatase that is > ULN but less than or equal to 2.5 x ULN or with unexplained bone pain are eligible for inclusion in the study if bone imaging (bone scan, PET-CT scan, or PET scan) supported by additional studies when indicated (CT, x-ray, MRI) performed within 28 days prior to randomization does not demonstrate metastatic disease.
Patients with N2 or N3 nodal disease or T3 primary disease must undergo liver and bone imaging (as described in 4.1.13 and 4.1.14) within 28 days prior to randomization, irrespective of baseline lab results, and studies must not demonstrate metastatic disease. Chest imaging with chest x-ray PA and Lateral, CT of the chest, or PET-CT must also be performed.
Creatinine clearance ≥ 50 mL/min (see Section 7.2.1 for instructions regarding calculation of creatinine clearance) performed within 28 days prior to randomization.
PT/INR ≤ ULN within 28 days of randomization. Patients receiving therapeutic anti-coagulants are not eligible.
A serum TSH and AM (morning) cortisol performed within 28 days prior to randomization to obtain a baseline value. Patients with abnormal TSH or AM cortisol baseline levels should be further evaluated and managed per institutional standards. Asymptomatic patients who require initiation or adjustment of medication or are followed without initiating treatment based on endocrinologist's recommendations are eligible.
LVEF assessment must be performed within 42 days prior to randomization. (LVEF assessment performed by echocardiogram is preferred; however, MUGA scan may be substituted based on institutional preferences.) The LVEF must be ≥ 55% regardless of the cardiac imaging facility's lower limit of normal.
For women of childbearing potential: agreement to remain abstinent (refrain from heterosexual intercourse) or use contraceptive methods that result in a failure rate of < 1% per year during the treatment period and for at least 5 months after the last dose of atezolizumab/placebo or 12 months after the last dose of chemotherapy.
A woman is considered to be of childbearing potential if she is not postmenopausal, has not reached a postmenopausal state (≥ 12 continuous months of amenorrhea with no identified cause other than menopause), and has not undergone surgical sterilization (removal of ovaries and/or uterus).
Examples of contraceptive methods with a failure rate of < 1% per year include: bilateral tubal ligation; male partner sterilization; hormonal contraceptives that inhibit ovulation; hormone-releasing intrauterine devices; copper intrauterine devices.
The reliability of sexual abstinence should be evaluated in relation to the duration of the clinical study and the preferred and usual lifestyle of the patient. Periodic abstinence (e.g., calendar, ovulation, symptothermal, or postovulation methods) and withdrawal are not acceptable methods of contraception.
Patient must be willing and able to comply with scheduled visits, treatment plans, laboratory tests, and other study procedures.
Exclusion Criteria:
Excisional biopsy or lumpectomy performed prior to study entry.
FNA alone to diagnose the breast cancer.
Surgical axillary staging procedure prior to randomization. Exception: FNA or core biopsy of an axillary node is permitted for any patient. A pre-neoadjuvant therapy sentinel lymph node biopsy for patients with clinically negative axillary nodes is prohibited.
Definitive clinical or radiologic evidence of metastatic disease.
Previous history of contralateral invasive breast cancer. (Patients with synchronous and/or previous contralateral DCIS or LCIS are eligible.)
Previous history of ipsilateral invasive breast cancer or ipsilateral DCIS. (Patients with synchronous or previous ipsilateral LCIS are eligible.)
History of non-breast malignancies (except for in situ cancers treated only by local excision and basal cell and squamous cell carcinomas of the skin) within 5 years prior to study entry.
Treatment including radiation therapy, chemotherapy, or targeted therapy, for the currently diagnosed breast cancer prior to randomization.
Previous therapy with anthracyclines or taxanes for any malignancy.
Cardiac disease (history of and/or active disease) that would preclude the use of the drugs included in the treatment regimens. This includes but is not confined to:
Active cardiac disease: angina pectoris that requires the use of anti-anginal medication; ventricular arrhythmias except for benign premature ventricular contractions; supraventricular and nodal arrhythmias requiring a pacemaker or not controlled with medication; conduction abnormality requiring a pacemaker; valvular disease with documented compromise in cardiac function; or symptomatic pericarditis.
History of cardiac disease: myocardial infarction documented by elevated cardiac enzymes or persistent regional wall abnormalities on assessment of left ventricular function within 6 months prior to randomization; history of documented CHF; or documented cardiomyopathy.
Uncontrolled hypertension defined as sustained systolic BP > 150 mmHg or diastolic BP > 90 mmHg. (Patients with initial BP elevations are eligible if initiation or adjustment of BP medication lowers pressure to meet entry criteria.) Patients requiring ≥ 3 BP medications are not eligible.
History of severe allergic, anaphylactic, or other hypersensitivity reactions to chimeric or humanized antibodies or fusion proteins.
Known hypersensitivity to biopharmaceuticals produced in Chinese hamster ovary cells.
Known allergy or hypersensitivity to the components of the atezolizumab formulation.
Known allergy or hypersensitivity to the components of the doxorubicin, epirubicin, cyclophosphamide, carboplatin, or paclitaxel formulations.
Known allergy or hypersensitivity to liposomal or pegylated G-CSF formulations.
Active or history of autoimmune disease or immune deficiency, including but not limited to myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, antiphospholipid syndrome, Wegener granulomatosis, Sjögren syndrome, Guillain-Barré syndrome, or multiple sclerosis for a more comprehensive list of autoimmune diseases and immune deficiencies) with the following exceptions:
Patients with a history of autoimmune-related hypothyroidism on a stable dose of thyroid replacement hormone may be eligible for this study.
Patients with controlled Type 1 diabetes mellitus on a stable dose of insulin regimen may be eligible for this study.
Patients with eczema, psoriasis, lichen simplex chronicus, or vitiligo with dermatologic manifestations only (e.g., patients with psoriatic arthritis are excluded) are permitted provided all of following conditions are met: Rash must cover < 10% of body surface area; Disease is well controlled at baseline and requires only low-potency topical corticosteroids; No occurrence of acute exacerbations of the underlying condition requiring psoralen plus ultraviolet A radiation, methotrexate, retinoids, biologic agents, oral calcineurin inhibitors, or high-potency or oral corticosteroids within the previous 12 months.
History of idiopathic pulmonary fibrosis, organizing pneumonia (e.g., bronchiolitis obliterans), drug-induced pneumonitis, idiopathic pneumonitis, or evidence of active pneumonitis on screening chest CT scan.
Patients known to be HIV positive.
Active hepatitis B virus (HBV) infection, defined as having a positive hepatitis B surface antigen (HBsAg) test at screening. Patients with a past or resolved HBV infection, defined as having a negative HBsAg test and a positive total hepatitis B core antibody (HBcAb) test at screening, are eligible for the study if active HBV infection is ruled out on the basis of HBV DNA viral load per local guidelines.
Active hepatitis C virus (HCV) infection, defined as having a positive HCV antibody test at screening confirmed by a polymerase chain reaction (PCR) positive for HCV RNA.
Patients with clinically active tuberculosis.
Severe infection within 28 days prior to randomization, including but not limited to hospitalization for complications of infection, bacteremia, or severe pneumonia.
Prior allogeneic stem cell or solid organ transplantation.
Administration of a live, attenuated vaccine within 28 days prior to randomization or anticipation that such vaccine will be required during the study. Patients must agree not to receive live, attenuated influenza vaccine (e.g., FluMist) within 28 days prior to randomization, during treatment or within 5 months following the last dose of atezolizumab/placebo.
Any other disease, metabolic dysfunction, physical examination finding, or clinical laboratory finding giving reasonable suspicion of a disease or condition that contraindicates the use of an investigational drug or that may affect the interpretation of the results or render the patient at high risk from treatment complications.
Prior treatment with CD137 agonists or immune checkpoint-blockade therapies, including anti-CD40, anti-CTLA-4, anti-PD-1, and anti-PD-L1 therapeutic antibodies.
Treatment with systemic immunosuppressive medications (including but not limited to interferons, IL-2) within 28 days or 5 half-lives of the drug, whichever is longer, prior to randomization.
Treatment with systemic immunosuppressive medications (including but not limited to prednisone, cyclophosphamide, azathioprine, methotrexate, thalidomide, and anti-tumor necrosis [anti-TNF] factor agents) within 14 days prior to randomization or anticipation of need for systemic immunosuppressive medications during the study.
Nervous system disorder (paresthesias, peripheral motor neuropathy, or peripheral sensory neuropathy) ≥ Grade 2, per the CTCAE v4.0.
Symptomatic peripheral ischemia.
Pregnancy or lactation at the time of randomization or intention to become pregnant during the study. (Note: Negative serum pregnancy test must be obtained within 14 days prior to randomization).
Use of any investigational agent within 28 days prior to randomization.
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There are 197 Locations for this study
Mobile Alabama, 36604, United States
Anchorage Alaska, 99508, United States
Jonesboro Arkansas, 72401, United States
Paragould Arkansas, 72450, United States
Anaheim California, 92806, United States
Baldwin Park California, 91706, United States
Bellflower California, 90706, United States
Colton California, 92324, United States
Duarte California, 91010, United States
Fontana California, 92335, United States
Harbor City California, 90710, United States
Irvine California, 92618, United States
Los Alamitos California, 90720, United States
Los Angeles California, 90027, United States
Los Angeles California, 90034, United States
Panorama City California, 91402, United States
Riverside California, 92505, United States
San Diego California, 92108, United States
San Diego California, 92120, United States
San Diego California, 92153, United States
San Marcos California, 92078, United States
South Pasadena California, 91030, United States
Torrance California, 90505, United States
Upland California, 91786, United States
Whittier California, 90602, United States
Woodland Hills California, 91367, United States
Aventura Florida, 33180, United States
Hollywood Florida, 33021, United States
Miami Beach Florida, 33140, United States
Orlando Florida, 32806, United States
Duluth Georgia, 30096, United States
Lawrenceville Georgia, 30046, United States
Snellville Georgia, 30078, United States
Bloomington Illinois, 61704, United States
Chicago Ridge Illinois, 60415, United States
Chicago Illinois, 60612, United States
Chicago Illinois, 60612, United States
Decatur Illinois, 62526, United States
Decatur Illinois, 62526, United States
Effingham Illinois, 62401, United States
Elmhurst Illinois, 60126, United States
Galesburg Illinois, 61401, United States
Naperville Illinois, 60540, United States
Ottawa Illinois, 61350, United States
Peoria Illinois, 61615, United States
Peru Illinois, 61354, United States
Plainfield Illinois, 60585, United States
Swansea Illinois, 62226, United States
Fort Wayne Indiana, 46804, United States
Fort Wayne Indiana, 46845, United States
Cedar Rapids Iowa, 52403, United States
Chanute Kansas, 66720, United States
Dodge City Kansas, 67801, United States
El Dorado Kansas, 67042, United States
Independence Kansas, 67301, United States
Kingman Kansas, 67068, United States
Liberal Kansas, 67901, United States
McPherson Kansas, 67460, United States
Newton Kansas, 67114, United States
Parsons Kansas, 67357, United States
Pratt Kansas, 67124, United States
Salina Kansas, 67401, United States
Wichita Kansas, 67214, United States
Wichita Kansas, 67214, United States
Winfield Kansas, 67156, United States
Louisville Kentucky, 40202, United States
Louisville Kentucky, 40202, United States
Louisville Kentucky, 40202, United States
Louisville Kentucky, 40207, United States
Louisville Kentucky, 40207, United States
Louisville Kentucky, 40241, United States
Kenner Louisiana, 70065, United States
Marrero Louisiana, 70072, United States
New Orleans Louisiana, 70112, United States
New Orleans Louisiana, 70121, United States
Baltimore Maryland, 21204, United States
Baltimore Maryland, 21218, United States
Baltimore Maryland, 21237, United States
Bethesda Maryland, 20817, United States
Brandywine Maryland, 20613, United States
Columbia Maryland, 21044, United States
Frederick Maryland, 21702, United States
Hagerstown Maryland, 21742, United States
Lanham Maryland, 20706, United States
Rockville Maryland, 20850, United States
Silver Spring Maryland, 20904, United States
Silver Spring Maryland, 20910, United States
Towson Maryland, 21204, United States
Wheaton Maryland, 20902, United States
Pittsfield Massachusetts, 01201, United States
Brownstown Michigan, 48183, United States
Clinton Township Michigan, 48038, United States
Dearborn Michigan, 48126, United States
Detroit Michigan, 48202, United States
East Lansing Michigan, 48823, United States
Jackson Michigan, 49201, United States
Lansing Michigan, 48910, United States
Novi Michigan, 48377, United States
West Bloomfield Michigan, 48322, United States
Wyandotte Michigan, 48192, United States
Columbia Missouri, 65212, United States
Newark New Jersey, 07112, United States
Voorhees New Jersey, 08043, United States
Albany New York, 12206, United States
Binghamton New York, 13905, United States
Johnson City New York, 13790, United States
Poughkeepsie New York, 12601, United States
Poughkeepsie New York, 12601, United States
Cary North Carolina, 27518, United States
Cary North Carolina, 27518, United States
Charlotte North Carolina, 28204, United States
Charlotte North Carolina, 28210, United States
Garner North Carolina, 27529, United States
High Point North Carolina, 27262, United States
Pinehurst North Carolina, 28374, United States
Raleigh North Carolina, 27607, United States
Raleigh North Carolina, 27607, United States
Raleigh North Carolina, 27614, United States
Rocky Mount North Carolina, 28704, United States
Fargo North Dakota, 58122, United States
Alliance Ohio, 44601, United States
Canton Ohio, 44710, United States
Canton Ohio, 44710, United States
Columbus Ohio, 43210, United States
Columbus Ohio, 43212, United States
Eugene Oregon, 97401, United States
Portland Oregon, 97227, United States
Tigard Oregon, 97223, United States
Beaver Pennsylvania, 15009, United States
Cranberry Township Pennsylvania, 16066, United States
Ephrata Pennsylvania, 17522, United States
Erie Pennsylvania, 16505, United States
Erie Pennsylvania, 16544, United States
Farrell Pennsylvania, 16121, United States
Gettysburg Pennsylvania, 17325, United States
Greensburg Pennsylvania, 15601, United States
Greenville Pennsylvania, 16125, United States
Jefferson Hills Pennsylvania, 15025, United States
Lebanon Pennsylvania, 17042, United States
Monroeville Pennsylvania, 15146, United States
Monroeville Pennsylvania, 15146, United States
N. Huntingdon Pennsylvania, 15642, United States
New Castle Pennsylvania, 16105, United States
Pittsburgh Pennsylvania, 15212, United States
Pittsburgh Pennsylvania, 15212, United States
Pittsburgh Pennsylvania, 15212, United States
Pittsburgh Pennsylvania, 15213, United States
Pittsburgh Pennsylvania, 15224, United States
Pittsburgh Pennsylvania, 15232, United States
Pittsburgh Pennsylvania, 15237, United States
Pittsburgh Pennsylvania, 15237, United States
Pittsburgh Pennsylvania, 15243, United States
Seneca Pennsylvania, 16346, United States
Uniontown Pennsylvania, 15401, United States
Washington Pennsylvania, 15301, United States
Wexford Pennsylvania, 15090, United States
York Pennsylvania, 17403, United States
York Pennsylvania, 17403, United States
Providence Rhode Island, 02905, United States
Greer South Carolina, 29651, United States
Spartanburg South Carolina, 29303, United States
Sioux Falls South Dakota, 57104, United States
Sioux Falls South Dakota, 57105, United States
Sioux Falls South Dakota, 57105, United States
Johnson City Tennessee, 37601, United States
Kingsport Tennessee, 37660, United States
Austin Texas, 72701, United States
Bedford Texas, 76022, United States
Carrollton Texas, 75010, United States
Dallas Texas, 75203, United States
Dallas Texas, 75230, United States
Dallas Texas, 75231, United States
Denton Texas, 76201, United States
Flower Mound Texas, 75028, United States
Houston Texas, 77030, United States
Houston Texas, 77030, United States
Houston Texas, 77054, United States
McAllen Texas, 78503, United States
Midland Texas, 79701, United States
Plano Texas, 75075, United States
The Woodlands Texas, 77380, United States
Bristol Virginia, 24201, United States
Leesburg Virginia, 20176, United States
Lynchburg Virginia, 24501, United States
Mechanicsville Virginia, 23116, United States
Midlothian Virginia, 23114, United States
Norton Virginia, 24273, United States
Richmond Virginia, 23226, United States
Auburn Washington, 98001, United States
Gig Harbor Washington, 98335, United States
Puyallup Washington, 98372, United States
Tacoma Washington, 98405, United States
Tacoma Washington, 98405, United States
Charleston West Virginia, 25304, United States
Morgantown West Virginia, 26506, United States
Burlington Wisconsin, 53105, United States
Fond Du Lac Wisconsin, 54937, United States
Germantown Wisconsin, 53022, United States
Grafton Wisconsin, 53024, United States
Green Bay Wisconsin, 54311, United States
Kenosha Wisconsin, 53142, United States
Milwaukee Wisconsin, 53209, United States
Milwaukee Wisconsin, 53215, United States
Milwaukee Wisconsin, 53215, United States
Milwaukee Wisconsin, 53227, United States
Milwaukee Wisconsin, 53233, United States
Oshkosh Wisconsin, 54904, United States
Racine Wisconsin, 53406, United States
Sheboygan Wisconsin, 53081, United States
Summit Wisconsin, 53066, United States
Two Rivers Wisconsin, 54241, United States
Wauwatosa Wisconsin, 53226, United States
Montréal Quebec, H1T2M, Canada
Montréal Quebec, H2XOA, Canada
Montréal Quebec, H3T 1, Canada
Montréal Quebec, H4A3J, Canada
Quebec City Quebec, G1S4L, Canada
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