Testing Low Dose Tamoxifen for Invasive Breast Cancer, the (LoTam) Trial

Phase 3

Recruiting

• Conditions: Anatomic Stage 0 Breast Cancer AJCC v8; Anatomic Stage 1 Breast Cancer AJCC v8; Anatomic Stage IIA Breast Cancer AJCC v8; Estrogen Receptor-Positive Breast Carcinoma; HER2-Negative Breast Carcinoma
• Interventions: Drug: Tamoxifen; Drug: Anastrozole; Procedure: Mammogram; Drug: Letrozole; Drug: Exemestane; Procedure: Magnetic Resonance Imaging; Biological: Dual X-ray Absorptiometry; Procedure: Biospecimen Collection; Other: Questionnaire Administration

• Registration Number: NCT06671912
• Lead Sponsor: Alliance for Clinical Trials in Oncology

Brief Summary

This phase III trial compares the effect of low dose tamoxifen to usual hormonal therapy, including aromatase inhibitors, in treating post-menopausal women with hormone positive, HER2 negative early stage breast cancer. Tamoxifen is in a class of medications known as antiestrogens. It blocks the activity of estrogen (a female hormone) in the breast. This may stop the growth of some breast tumors that need estrogen to grow. Aromatase inhibitors, such as anastrozole, letrozole, and exemestane, prevent the formation of estradiol, a female hormone, by interfering with an aromatase enzyme. Aromatase inhibitors are used as a type of hormone therapy to treat postmenopausal women with hormone-dependent breast cancer. Giving low dose tamoxifen may be more effective compared to usual hormone therapy in treating post-menopausal women with hormone-positive, HER2 negative early stage breast cancer.

Detailed Description

The primary and secondary objectives of the study:

PRIMARY OBJECTIVE:

I. To evaluate whether the recurrence-free interval (RFI) with low-dose tamoxifen is non-inferior to standard-of-care endocrine therapy among post-menopausal women with early-stage, low molecular risk breast cancer.

SECONDARY OBJECTIVES:

I. To compare endocrine therapy nonadherence rates between treatment arms. II. To compare the incidence of adverse events between treatment arms, including osteoporosis, fracture, endometrial carcinoma, stroke, and deep vein thrombosis.

III. To compare endocrine therapy-related patient reported symptoms between treatment arms.

IV. To compare the invasive disease-free survival between treatment arms. V. To compare the locoregional breast cancer recurrence between treatment arms. VI. To compare distant recurrence free survival between treatment arms. VII. To compare overall survival between treatment arms. VIII. To compare ductal carcinoma in situ (DCIS) incidence (ipsilateral and contralateral) between treatment arms.

IX. To evaluate the association between radiotherapy modality (no radiation, partial breast radiation, and whole breast radiation) and RFI in each arm.

X. To explore important measures of quality of life that would reasonably be expected to vary by study arm, including global quality of life and reasons for nonadherence.

XI. To compare change in mammographic density at two years between treatment arms.

XII. To conduct a within patient comparison of automated versus (vs) semi-automated mammographic density determination.

OUTLINE: Patients are randomized to 1 of 2 arms.

ARM I: Patients receive standard of care endocrine therapy per physician choice with either anastrozole orally (PO), letrozole PO, exemestane PO or standard dose tamoxifen PO once daily (QD) for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or magnetic resonance imaging (MRI), dual X-ray absorptiometry (DEXA), and blood sample collection on study.

ARM II: Patients receive low-dose tamoxifen PO every other day (QOD) for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.

After completion of study treatment, patients are followed up for 10 years after registration.

Study Timeline

• Study First Submitted: 2024-11-01
• Study First Submitted QC: 2024-11-01
• Study First Posted: 2024-11-04
• Status Verified: 2025-03
• Last Update Submitted: 2025-03-28
• Last Update Posted: 2025-04-02
• Study Start: 2025-04-15
• Primary Completion: 2030-11-30
• Study Completion: 2031-11-30

Recruitment & Eligibility

• Status: RECRUITING
• Sex: All
• Target Recruitment: 1156

Inclusion Criteria

• Unilateral invasive adenocarcinoma of the breast that is histologically confirmed

  • Invasive breast cancer is estrogen receptor positive in ≥ 10% of cells
  • HER2 negative by current American Society of Clinical Oncology (ASCO)/College of American Pathologists (CAP) guidelines

• The patient must have a multigene assay with a low-risk score, including any of the following (if more than one genomic assay was obtained, both are required to be low-risk):

  • Oncotype DX recurrence score ≤ 25
  • Mamma Print low risk
  • Prosigna risk of recurrence ≤ 40

• Tumor size must be ≤ 3 cm by pathologic evaluation

• Adequate surgical removal of all clinically evident disease in the breast with either breast conserving surgery or mastectomy. Negative margins on final pathology are required. Additional excisions may be performed to obtain clear margins before registration

• No clinical (cN1, cN2, cN3) or pathologic (pN1mi, pN1, pN2, or pN3) evidence of lymph node involvement on either needle biopsy or surgical lymph node assessment. Patients with pN0(i+) or pN0 (mol+) are eligible

  • Surgical axillary staging (sentinel lymph node biopsy ± axillary lymph node dissection) is completed according to physician discretion
  • For patients with negative preoperative axillary ultrasonography, clinicians may selectively choose to forego surgical axillary staging. Ipsilateral axillary ultrasound showing no lymph node involvement with no evidence of lymphadenopathy or suspicious thickening is required in this scenario

• No pathological tumor size > 3 cm or pT4

• No definitive clinical or radiologic evidence of metastatic disease

• No palpable or radiographically suspicious axillary, supraclavicular, infraclavicular, or internal mammary lymph nodes, unless there is histologic confirmation that these lymph nodes are negative for tumor

• No suspicious microcalcifications, densities, or palpable abnormalities in the ipsilateral or contralateral breast, unless biopsied and found to be benign

• An interval of no more than 20 weeks between the date of surgery and the date of registration

• Must have had a bilateral mammogram or MRI within 6 months prior to registration

• Must be intending to take endocrine therapy for at least 5 years duration

• No prior treatment with endocrine therapy or chemotherapy for the currently diagnosed breast cancer prior to registration. (Short course endocrine therapy of ≤ 6 weeks duration is acceptable after core biopsy and before surgery, if genomic testing is assessed on the biopsy core and meets eligibility requirements for a low-risk score.)

• No use of oral hormone replacement therapy within 7 days prior to registration

• Age ≥ 18 years

• Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2

• Postmenopausal status confirmed as:

  • No spontaneous menses ≥ 1 year
  • No menses for < 1 year with follicle stimulating hormone (FSH) and estradiol levels within a postmenopausal range according to institutional standards
  • Previous bilateral surgical oophorectomy

• None of the following conditions:

  • Abnormal or dysfunctional uterine bleeding within 1 year prior to study enrollment
  • Any patient with known atypia or endometrial pathology that the opinion of the treating investigator would place the patient at undue risk of endometrial cancer with tamoxifen.
  • Any patient with a known hypercoagulable state that in the opinion of the treating investigator would put the patient at undue risk of venous thromboembolism with tamoxifen

• No history of breast or thoracic radiotherapy for any previous condition. Patients may complete radiotherapy for the currently diagnosed breast cancer prior to registering for the study. In this scenario, registration must be completed within 12 weeks of completing breast radiotherapy

• No previous history of ipsilateral invasive breast cancer or ipsilateral ductal carcinoma in situ (DCIS), regardless of the disease-free interval

• No synchronous or previous contralateral invasive or non-invasive breast cancer

• 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

• No patients with premenopausal status

• No current treatment with any endocrine therapy for breast cancer prevention or osteoporosis, including raloxifene, tamoxifen, or other selective estrogen receptor modulator. Patients intending to continue oral hormone replacement are not eligible

• HIV-infected patients on effective anti-retroviral therapy with undetectable viral load within 6 months are eligible for this trial

Exclusion Criteria

Not provided

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Arm I (anastrozole, letrozole, exemestane, tamoxifen)	Questionnaire Administration	Patients receive standard of care endocrine therapy per physician choice with either anastrozole PO, letrozole PO, exemestane PO or standard dose tamoxifen PO QD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm II (low dose tamoxifen)	Tamoxifen	Patients receive low-dose tamoxifen PO QOD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm II (low dose tamoxifen)	Mammogram	Patients receive low-dose tamoxifen PO QOD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm I (anastrozole, letrozole, exemestane, tamoxifen)	Anastrozole	Patients receive standard of care endocrine therapy per physician choice with either anastrozole PO, letrozole PO, exemestane PO or standard dose tamoxifen PO QD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm I (anastrozole, letrozole, exemestane, tamoxifen)	Letrozole	Patients receive standard of care endocrine therapy per physician choice with either anastrozole PO, letrozole PO, exemestane PO or standard dose tamoxifen PO QD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm I (anastrozole, letrozole, exemestane, tamoxifen)	Exemestane	Patients receive standard of care endocrine therapy per physician choice with either anastrozole PO, letrozole PO, exemestane PO or standard dose tamoxifen PO QD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm I (anastrozole, letrozole, exemestane, tamoxifen)	Tamoxifen	Patients receive standard of care endocrine therapy per physician choice with either anastrozole PO, letrozole PO, exemestane PO or standard dose tamoxifen PO QD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm I (anastrozole, letrozole, exemestane, tamoxifen)	Mammogram	Patients receive standard of care endocrine therapy per physician choice with either anastrozole PO, letrozole PO, exemestane PO or standard dose tamoxifen PO QD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm I (anastrozole, letrozole, exemestane, tamoxifen)	Magnetic Resonance Imaging	Patients receive standard of care endocrine therapy per physician choice with either anastrozole PO, letrozole PO, exemestane PO or standard dose tamoxifen PO QD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm I (anastrozole, letrozole, exemestane, tamoxifen)	Dual X-ray Absorptiometry	Patients receive standard of care endocrine therapy per physician choice with either anastrozole PO, letrozole PO, exemestane PO or standard dose tamoxifen PO QD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm I (anastrozole, letrozole, exemestane, tamoxifen)	Biospecimen Collection	Patients receive standard of care endocrine therapy per physician choice with either anastrozole PO, letrozole PO, exemestane PO or standard dose tamoxifen PO QD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm II (low dose tamoxifen)	Magnetic Resonance Imaging	Patients receive low-dose tamoxifen PO QOD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm II (low dose tamoxifen)	Dual X-ray Absorptiometry	Patients receive low-dose tamoxifen PO QOD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm II (low dose tamoxifen)	Biospecimen Collection	Patients receive low-dose tamoxifen PO QOD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.
Arm II (low dose tamoxifen)	Questionnaire Administration	Patients receive low-dose tamoxifen PO QOD for up to 5 years in the absence of disease progression or unacceptable toxicity. Patients may also undergo mammogram or MRI, DEXA, and blood sample collection on study.

Primary Outcome Measures

Name	Time	Method
Recurrence-free interval (RFI)	From randomization to the first of the following breast cancer events: invasive ipsilateral breast or chest wall recurrence, regional recurrence, distant recurrence, and death from breast cancer up to 5 years	The Kaplan-Meier method will be used to estimate the distribution of RFI times and a stratified log-rank test for non-inferiority will be used to assess whether RFI with low-dose tamoxifen is non-inferior to standard-of-care endocrine therapy in this patient population. Stratified Cox modeling will be used to estimate the hazard ratio and corresponding one-sided 95% confidence interval (CI).

Secondary Outcome Measures

Name	Time	Method
Endocrine therapy extent of nonadherence	Up to 5 years	The proportion of patients who stopped treatment early will be compared between the two treatment arms with a chi-square test. Additional analyses will be performed with respect to nonadherence. The proportion of patients who report any nonadherence will be compared between the two treatment arms using generalized estimating equations for logistic regression
Physician reported incidence of adverse events (AEs)	Up to 10 years	AEs will be evaluated and graded using the Common Terminology Criteria for Adverse Events version 5.0 with special focus on the incidence of fracture, osteoporosis, stroke and thromboembolic events.
Patient reported toxicities	At baseline and up to 10 years	Patient reported symptoms assessed using Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (PRO-CTCAE). The proportion of patients with a maximum post-baseline score greater than 0 will be compared between arms using Fisher's exact test. The proportion of patients with a maximum post-baseline score greater than or equal to 3 will be compared between arms using Fisher's exact test. The same procedure will be applied to patients' maximum baseline-adjusted scores. Patients' maximum baseline-adjusted scores will be calculated using the method described by Dueck et al. The proportion of patients who report a grade 3 or higher AEs using PRO-CTCAE will be compared between the two treatment arms with a chi-square test. The proportion of patients with reported grade 3 or higher endocrine-related adverse event (any one of fracture, stroke, or deep vein thrombosis) will be compared with a chi-square test or Fisher's exact test, whichever is more appropriate.
Invasive disease-free survival (iDFS)	Up to 10 years	IDFS will be defined as local, regional or distant recurrences, or contralateral invasive breast cancer, second non-breast primary cancer, and death from any cause. IDFS will be compared between the treatment arms with a stratified log rank test and a stratified Cox model will be used to generate the hazard ratio estimates (both a point estimate and a 95% CI).
Locoregional recurrence free-survival (LRFS)	From randomization until invasive tumor recurs in the ipsilateral breast or chest wall, axillary, supraclavicular, or internal mammary nodes up to 10 years	LRFS will be defined as the time from randomization until invasive tumor recurs in the ipsilateral breast or chest wall, axillary, supraclavicular, or internal mammary nodes (if before or synchronous with a systemic recurrence), whichever comes first. LRFS will be compared between the treatment arms with a stratified log rank test and a stratified Cox model will be used to generate the hazard ratio estimates (both a point estimate and a 95% CI).
Distant disease-free survival (DDFS)	From randomization until the tumor recurs distantly or death up to 10 years	DDFS will be defined as the time from randomization until the tumor recurs distantly, or the patient dies, whichever comes first. DDFS will be compared between the treatment arms with a stratified log rank test and a stratified Cox model will be used to generate the hazard ratio estimates (both a point estimate and a 95% CI).
Overall survival (OS)	From randomization until death up to 10 years	OS will be defined as the time from randomization until death due to any cause. OS will be compared between the treatment arms with a stratified log rank test and a stratified Cox model will be used to generate the hazard ratio estimates (both a point estimate and a 95% CI).
Cumulative incidence rate of ductal carcinoma in situ (DCIS)	From randomization until the occurrence of an ipsilateral or contralateral DCIS diagnosis up to 10 years	Cumulative incidence rate of DCIS will be measured as the time from randomization until the occurrence of an ipsilateral or contralateral DCIS diagnosis. The cumulative incidence of DCIS will be analyzed with Kaplan-Meier estimates (curve starting at 0 rather than 1) and compared with a log rank test.

Trial Locations

Locations (113)

Bon Secours Saint Mary's Hospital; 🇺🇸 Richmond, Virginia, United States

Keck Medicine of USC Buena Park; 🇺🇸 Buena Park, California, United States

Enloe Medical Center; 🇺🇸 Chico, California, United States

Kaiser Permanente Dublin; 🇺🇸 Dublin, California, United States

Kaiser Permanente-Fremont; 🇺🇸 Fremont, California, United States

Kaiser Permanente-Fresno; 🇺🇸 Fresno, California, United States

Los Angeles General Medical Center; 🇺🇸 Los Angeles, California, United States

USC / Norris Comprehensive Cancer Center; 🇺🇸 Los Angeles, California, United States

Kaiser Permanente-Modesto; 🇺🇸 Modesto, California, United States

USC Norris Oncology/Hematology-Newport Beach; 🇺🇸 Newport Beach, California, United States

Kaiser Permanente-Oakland; 🇺🇸 Oakland, California, United States

Kaiser Permanente-Roseville; 🇺🇸 Roseville, California, United States

Kaiser Permanente Downtown Commons; 🇺🇸 Sacramento, California, United States

Kaiser Permanente-South Sacramento; 🇺🇸 Sacramento, California, United States

Kaiser Permanente-San Francisco; 🇺🇸 San Francisco, California, United States

Kaiser Permanente-Santa Teresa-San Jose; 🇺🇸 San Jose, California, United States

Kaiser Permanente San Leandro; 🇺🇸 San Leandro, California, United States

Kaiser San Rafael-Gallinas; 🇺🇸 San Rafael, California, United States

Kaiser Permanente Medical Center - Santa Clara; 🇺🇸 Santa Clara, California, United States

Kaiser Permanente-Santa Rosa; 🇺🇸 Santa Rosa, California, United States

Kaiser Permanente-South San Francisco; 🇺🇸 South San Francisco, California, United States

Gene Upshaw Memorial Tahoe Forest Cancer Center; 🇺🇸 Truckee, California, United States

Kaiser Permanente-Vallejo; 🇺🇸 Vallejo, California, United States

Kaiser Permanente-Walnut Creek; 🇺🇸 Walnut Creek, California, United States

Stamford Hospital/Bennett Cancer Center; 🇺🇸 Stamford, Connecticut, United States

Beebe South Coastal Health Campus; 🇺🇸 Millville, Delaware, United States

Helen F Graham Cancer Center; 🇺🇸 Newark, Delaware, United States

Kaiser Permanente-Caton Hill Medical Center; 🇺🇸 Woodbridge, Virginia, United States

Medical Oncology Hematology Consultants PA; 🇺🇸 Newark, Delaware, United States

Beebe Health Campus; 🇺🇸 Rehoboth Beach, Delaware, United States

Kaiser Permanente-Capitol Hill Medical Center; 🇺🇸 Washington, District of Columbia, United States

Kaiser Permanente Moanalua Medical Center; 🇺🇸 Honolulu, Hawaii, United States

Kootenai Health - Coeur d'Alene; 🇺🇸 Coeur d'Alene, Idaho, United States

Kootenai Clinic Cancer Services - Post Falls; 🇺🇸 Post Falls, Idaho, United States

Langlade Hospital and Cancer Center; 🇺🇸 Antigo, Wisconsin, United States

Kootenai Clinic Cancer Services - Sandpoint; 🇺🇸 Sandpoint, Idaho, United States

Illinois CancerCare-Bloomington; 🇺🇸 Bloomington, Illinois, United States

Illinois CancerCare-Canton; 🇺🇸 Canton, Illinois, United States

ThedaCare Regional Cancer Center; 🇺🇸 Appleton, Wisconsin, United States

Saint Vincent Hospital Cancer Center Green Bay; 🇺🇸 Green Bay, Wisconsin, United States

Saint Vincent Hospital Cancer Center at Saint Mary's; 🇺🇸 Green Bay, Wisconsin, United States

Aspirus Medford Hospital; 🇺🇸 Medford, Wisconsin, United States

Illinois CancerCare-Carthage; 🇺🇸 Carthage, Illinois, United States

Carle at The Riverfront; 🇺🇸 Danville, Illinois, United States

Cancer Care Specialists of Illinois - Decatur; 🇺🇸 Decatur, Illinois, United States

Decatur Memorial Hospital; 🇺🇸 Decatur, Illinois, United States

Illinois CancerCare-Dixon; 🇺🇸 Dixon, Illinois, United States

Saint Vincent Hospital Cancer Center at Oconto Falls; 🇺🇸 Oconto Falls, Wisconsin, United States

Aspirus Cancer Care - James Beck Cancer Center; 🇺🇸 Rhinelander, Wisconsin, United States

Saint Vincent Hospital Cancer Center at Sheboygan; 🇺🇸 Sheboygan, Wisconsin, United States

Carle Physician Group-Effingham; 🇺🇸 Effingham, Illinois, United States

Crossroads Cancer Center; 🇺🇸 Effingham, Illinois, United States

Illinois CancerCare-Eureka; 🇺🇸 Eureka, Illinois, United States

Illinois CancerCare-Galesburg; 🇺🇸 Galesburg, Illinois, United States

Illinois CancerCare-Kewanee Clinic; 🇺🇸 Kewanee, Illinois, United States

Springfield Memorial Hospital; 🇺🇸 Springfield, Illinois, United States

McFarland Clinic - Ames; 🇺🇸 Ames, Iowa, United States

Mercy Hospital; 🇺🇸 Cedar Rapids, Iowa, United States

Sheboygan Phyisicans Group; 🇺🇸 Sheboygan, Wisconsin, United States

Aspirus Cancer Care - Stevens Point; 🇺🇸 Stevens Point, Wisconsin, United States

Saint Vincent Hospital Cancer Center at Sturgeon Bay; 🇺🇸 Sturgeon Bay, Wisconsin, United States

Aspirus Cancer Care - Wisconsin Rapids; 🇺🇸 Wisconsin Rapids, Wisconsin, United States

Illinois CancerCare-Macomb; 🇺🇸 Macomb, Illinois, United States

Carle Physician Group-Mattoon/Charleston; 🇺🇸 Mattoon, Illinois, United States

Illinois CancerCare-Peoria; 🇺🇸 Peoria, Illinois, United States

Aspirus Regional Cancer Center; 🇺🇸 Wausau, Wisconsin, United States

Illinois CancerCare-Ottawa Clinic; 🇺🇸 Ottawa, Illinois, United States

Southern Illinois University School of Medicine; 🇺🇸 Springfield, Illinois, United States

Illinois CancerCare - Washington; 🇺🇸 Washington, Illinois, United States

Mary Greeley Medical Center; 🇺🇸 Ames, Iowa, United States

Oncology Associates at Mercy Medical Center; 🇺🇸 Cedar Rapids, Iowa, United States

McFarland Clinic - Trinity Cancer Center; 🇺🇸 Fort Dodge, Iowa, United States

McFarland Clinic - Marshalltown; 🇺🇸 Marshalltown, Iowa, United States

Doctors Cancer Center; 🇵🇷 Manati, Puerto Rico

Illinois CancerCare-Pekin; 🇺🇸 Pekin, Illinois, United States

Illinois CancerCare-Princeton; 🇺🇸 Princeton, Illinois, United States

Carle Cancer Center; 🇺🇸 Urbana, Illinois, United States

Kaiser Permanente-Gaithersburg Medical Center; 🇺🇸 Gaithersburg, Maryland, United States

Centro Comprensivo de Cancer de UPR; 🇵🇷 San Juan, Puerto Rico

PROncology; 🇵🇷 San Juan, Puerto Rico

San Juan City Hospital; 🇵🇷 San Juan, Puerto Rico

Illinois CancerCare-Peru; 🇺🇸 Peru, Illinois, United States

Springfield Clinic; 🇺🇸 Springfield, Illinois, United States

McFarland Clinic - Boone; 🇺🇸 Boone, Iowa, United States

McFarland Clinic - Jefferson; 🇺🇸 Jefferson, Iowa, United States

Kaiser Permanente-Woodlawn Medical Center; 🇺🇸 Baltimore, Maryland, United States

OSF Saint Francis Hospital and Medical Group; 🇺🇸 Escanaba, Michigan, United States

Saint Francis Medical Center; 🇺🇸 Cape Girardeau, Missouri, United States

Parkland Health Center - Farmington; 🇺🇸 Farmington, Missouri, United States

Missouri Baptist Medical Center; 🇺🇸 Saint Louis, Missouri, United States

Sainte Genevieve County Memorial Hospital; 🇺🇸 Sainte Genevieve, Missouri, United States

Missouri Baptist Sullivan Hospital; 🇺🇸 Sullivan, Missouri, United States

BJC Outpatient Center at Sunset Hills; 🇺🇸 Sunset Hills, Missouri, United States

Billings Clinic Cancer Center; 🇺🇸 Billings, Montana, United States

Ochsner Medical Center Jefferson; 🇺🇸 New Orleans, Louisiana, United States

Kaiser Permanente - Largo Medical Center; 🇺🇸 Largo, Maryland, United States

Kaiser Permanente Lutherville - Timonium Medical Center; 🇺🇸 Lutherville, Maryland, United States

Bozeman Health Deaconess Hospital; 🇺🇸 Bozeman, Montana, United States

Benefis Sletten Cancer Institute; 🇺🇸 Great Falls, Montana, United States

Kaiser Permanente Tysons Corner Medical Center; 🇺🇸 McLean, Virginia, United States

Community Medical Center; 🇺🇸 Missoula, Montana, United States

Roswell Park Cancer Institute; 🇺🇸 Buffalo, New York, United States

Hematology Oncology Associates of Central New York-East Syracuse; 🇺🇸 East Syracuse, New York, United States

Good Samaritan Hospital - Cincinnati; 🇺🇸 Cincinnati, Ohio, United States

Women and Infants Hospital; 🇺🇸 Providence, Rhode Island, United States

Rapid City Regional Hospital; 🇺🇸 Rapid City, South Dakota, United States

MD Anderson in The Woodlands; 🇺🇸 Conroe, Texas, United States

M D Anderson Cancer Center; 🇺🇸 Houston, Texas, United States

MD Anderson West Houston; 🇺🇸 Houston, Texas, United States

MD Anderson League City; 🇺🇸 League City, Texas, United States

MD Anderson in Sugar Land; 🇺🇸 Sugar Land, Texas, United States

Bon Secours Memorial Regional Medical Center; 🇺🇸 Mechanicsville, Virginia, United States

Bon Secours Saint Francis Medical Center; 🇺🇸 Midlothian, Virginia, United States