T-DM1 vs Paclitaxel/Trastuzumab for Breast (ATEMPT Trial)

Phase 2

Active, not recruiting

Conditions: Breast Cancer

Interventions: Drug: Trastuzumab
Drug: Trastuzumab emtansine
Drug: Paclitaxel

Registration Number: NCT01853748

Lead Sponsor: Dana-Farber Cancer Institute

Brief Summary: This research study is a Phase II clinical trial. Phase II clinical trials test the effectiveness of an investigational drug to learn whether the drug works in treating a specific cancer. "Investigational" means that the drug is still being studied and that research doctors are trying to find out more about it-such as the safest dose to use, the side effects it may cause, and if the drug is effective for treating different types of cancer. It also means that the FDA has not approved this drug for use patients undergoing adjuvant treatment for HER2+ breast cancer. Trastuzumab emtansine (T-DM1) is a drug that may stop cancer cells from growing. This drug has been used in other research studies and information from those other research studies suggests that this drug may help to prevent the recurrence of breast cancer in this research study.

The use of T-DM1 in this research study is experimental, which means it is not approved by any regulatory authority for the adjuvant treatment of HER2-positive breast cancer. However, it FDA-approved for metastatic HER2-positive breast cancer. T-DM1 has caused cancer cells to die in laboratory studies. In preclinical studies, this drug has prevented or slowed the growth of breast cancer. The breast cancer treatments (paclitaxel and Trastuzumab) used in this study are considered part of standard-of-care regimens in early breast cancer. A standard treatment means that this is a treatment that would be accepted by the majority of the medical community as a suitable treatment for your type of breast cancer.

In this research study, the investigators are looking to see if the study drug T-DM1 will have less side effects than traditional HER2-positive breast cancer treatment of trastuzumab and paclitaxel. The investigators are also hoping to learn about the long term benefits and disease-free survival of participants who take the study drug T-DM1 in comparison to those participants to take the combination of trastuzumab and paclitaxel.

Detailed Description: If a participant agrees to participate in this study she will be asked to undergo some screening tests or procedures to confirm that she is eligible. Many of these tests and procedures are likely to be part of regular cancer care and may be done even if turns out that she does not take part in this research study. If she has had some of these tests or procedures recently, they may or may not have to be repeated. These tests and procedures will include: a medical history, performance status, assessment of your tumor, blood tests, cardiac tests, pregnancy test and a collection of tumor tissue. If these tests show that she is eligible to participate in the research study, she will begin the study treatment. If she does not meet the eligibility criteria, she will not be able to participate in this research study.

Because no one knows which of the study options is best, the participant will be "randomized" into one of the study groups after she has had her breast surgery: Group 1 or Group 2. Randomization means that she is put into a group by chance. Neither the participant nor the research doctor will choose what group she will be in. The participant will have a one in three chance of being placed in any group. Approximately 375 study participants will receive the study drug, while 125 study participants will receive the standard therapy of trastuzumab and paclitaxel.

Group 1 participants will receive the study drug T-DM1 every three weeks by IV (intravenous injection) for 17 treatments (total of 51 weeks).

Group 2 participants will receive the FDA-approved drugs Paclitaxel and Trastuzumab once per week by IV for 12 weeks. Then beginning week 13, participants will receive Trastuzumab only by IV injection every three weeks for the next 13 treatments.

During all cycles the participant will have a physical exam and tumor assessment.

The investigators would like to keep track of the participant's medical condition for the next five years after the final dose of study drug. The investigators would like to do this by regular visits every 6 months for 3 years after completion of study treatment, and then once a year for the next two years. The investigators may ask for additional follow-up by phone after completion of these visits.

Participants who undergo lumpectomy (breast conserving surgery) need to receive breast radiation therapy to participate in this study. Participants who have undergone a mastectomy may receive chest wall and lymph node radiation (as determined by discussion with their physician). Radiation Therapy will begin after the conclusion of all study paclitaxel doses, and after 12 weeks fo the study drug T-DM1.

Recruitment & Eligibility

Status: ACTIVE_NOT_RECRUITING

Sex: All

Target Recruitment: 512

Inclusion Criteria

HER2-positive Stage I histologically confirmed invasive carcinoma of the breast
ER/PR determination is required
HER2 positive, confirmed by central testing: IHC 3+, FISH HER2/CEP17 <2.0 with an average HER2 copy number >/=6.0, or FISH HER2/CEP17 >/= 2.0
Bilateral breast cancers that individually meet eligibility criteria are allowed
Subjects with multifocal or multicentric disease are eligible as long as each tumor individually meets eligibility criteria
Subjects with a history of ipsilateral DCIS are eligible if they were treated with wide-excision alone, without radiation therapy; Patients with a history of contralateral DCIS are not eligible.
Should have tumor tissue available and a tissue block of sufficient size to make 15 slides, which must be sent to a DFCI site for testing
Less than or equal to 90 days since most recent breast surgery for this breast cancer
All tumor should be removed by either a modified radical mastectomy or a segmental mastectomy (lumpectomy) with either a sentinel node biopsy or axillary dissection
All margins should be clear of invasive cancer or DCIS
May have received up to 4 weeks of tamoxifen therapy or other hormonal therapy, for adjuvant therapy for this cancer
Prior oophorectomy for cancer prevention is allowed
Subjects who have undergone partial breast radiation (duration </= 7 days) prior to registration are eligible. Partial breast radiation must be completed prior to 2 weeks before starting protocol therapy.
Must have discontinued any investigational drug at least 2 weeks prior to participation
Willing to use one highly effective from of nonhormonal contraception or two effective forms of nonhormonal contraception while on study and for 7 months after end of study treatment
Subjects undergoing lumpectomy must have no contraindications to radiation therapy

Exclusion Criteria

Pregnant or breastfeeding
Use of potent CYP3A4 inhibitors during the study treatment period
Excessive alcohol intake (more than 3 alcoholic beverages per day)
Locally advanced tumors at diagnosis
History of previous invasive breast cancer
History of prior chemotherapy in the past 5 years
History of prior trastuzumab or prior paclitaxel therapy
Active, unresolved infection
Active liver disease
History of a different malignancy except for the following: disease free for at least 5 years and at low risk for recurrence; cervical cancer in situ, basal or squamous cell carcinoma of the skin
Active cardiac disease

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Paclitaxel + Trastuzumab	Trastuzumab	paclitaxel 80 mg/m2 IV weekly and trastuzumab 4 mg/kg IV load, followed by 2 mg/kg IV weekly for 12 weeks, followed by trastuzumab 6 mg/kg IV every 3 weeks for 13 treatments
Trastuzumab emtansine (T-DM1)	Trastuzumab emtansine	T-DM1 3.6mg/kg every three weeks by IV for 17 doses for a total of 51 weeks
Paclitaxel + Trastuzumab	Paclitaxel	paclitaxel 80 mg/m2 IV weekly and trastuzumab 4 mg/kg IV load, followed by 2 mg/kg IV weekly for 12 weeks, followed by trastuzumab 6 mg/kg IV every 3 weeks for 13 treatments

Primary Outcome Measures

Name	Time	Method
3-year Disease Free Survival (DFS) Rate of Trastuzumab Emtansine (TDM-1)	3 years	Disease-free survival (DFS) is evaluated and defined per protocol: from the time of randomization until the to the occurrence of the first of the following events: * Local/regional recurrence: a recurrent or new invasive ipsilateral breast cancer, invasive breast cancer in the axilla, regional lymph nodes, chest wall, or skin of the ipsilateral breast. * Contralateral invasive breast cancer, * Distant recurrence: metastatic disease that has either been biopsy confirmed or clinically diagnosed as recurrent invasive breast cancer. A single new lesion on a bone scan without evidence of lytic disease on x-ray and without symptoms does not in and of itself constitute distant recurrence, but multiple new bone lesions, or increased isotope uptake associated with new bone symptoms are more likely due to metastases. Bone metastases must be documented with x-rays and clinical description. * Death from any cause
Number of Participants of Clinically Relevant Toxicities (CRT)	5 years after completion of study treatment or until death, whichever occurs first.	Clinically relevant toxicities will include the composite incidence of grade 3 or higher non-hematologic toxicity, grade 2 or higher neurotoxicity, and grade 4 or higher hematologic toxicity. These toxicities will only be assessed at the pre-specified toxicity-assessment visits. In addition, the following events, regardless of timing of their occurrence, will also count towards the composite endpoint: febrile neutropenia, any toxicity requiring dose-delay, discontinuation of any study treatment (Paclitaxel, Trastuzumab, or T-DM1) for toxicity, and any serious adverse event (SAE).

Secondary Outcome Measures

Name	Time	Method
Quality of Life (QOL) FACT B Total Score at 1 Year	at 1 year	The QOL assessments questionnaire should be completed via the tablet provided by the study or on any available computer with an internet connection. The FACT-B questionnaire consists of five subscale, listed below: Physical well being(PWB): range 0-28 Social/Family well being(SWB): range 0-28 Emotional well being(EWB): range 0-24 Functional well being(FWB): range 0-28 Breast cancer subscale(BCS): range 0-40 The total score (FACTB) is calculated by summarizing all the subscales listed above, therefore it ranges from 0 to 148. The higher the score the better the outcome (applies to all sub-scales as well).
Percentage of Activity Impairment Because of Health	Surveys are took at week 3, 12 and month 6 and 12 during treatment, and month 18, 24, 30 and 36 during follow up.	Effects of therapy on work productivity and activity - Activity Impairment because of health, evaluated using the Work Productivity and Activity Impairment Questionnaire (WPAI-SHP), which defined per protocol.
3-year T-DM1 iDFS Percentage by Tumor Size and Hormone Receptor (HR) Status	3 years	Disease-free survival (DFS) is evaluated in patients treated with trastuzumab emtansine, which is defined per protocol: from the time of randomization until the to the occurrence of the first of the following events: * Local/regional recurrence: a recurrent or new invasive ipsilateral breast cancer, invasive breast cancer in the axilla, regional lymph nodes, chest wall, or skin of the ipsilateral breast. * Contralateral invasive breast cancer, * Distant recurrence: metastatic disease that has either been biopsy confirmed or clinically diagnosed as recurrent invasive breast cancer. A single new lesion on a bone scan without evidence of lytic disease on x-ray and without symptoms does not in and of itself constitute distant recurrence, but multiple new bone lesions, or increased isotope uptake associated with new bone symptoms are more likely due to metastases. Bone metastases must be documented with x-rays and clinical description. * Death from any cause
Quality of Life (QOL) FACT B Total Score at Week 12	at week 12	The QOL assessments questionnaire should be completed via the tablet provided by the study or on any available computer with an internet connection. The FACT-B questionnaire consists of five subscale, listed below: Physical well being(PWB): range 0-28 Social/Family well being(SWB): range 0-28 Emotional well being(EWB): range 0-24 Functional well being(FWB): range 0-28 Breast cancer subscale(BCS): range 0-40 The total score (FACTB) is calculated by summarizing all the subscales listed above, therefore it ranges from 0 to 148. The higher the score the better the outcome (applies to all sub-scales as well).
Number of Patients Has Neuropathy	Surveys are took at week 3, 12 and month 6 and 12 during treatment, and month 18. The data cutoff date is 18 month.	Neuropathy evaluated by Patient Neurotoxicity Questionnaire (PNQ) defined per protocol.
Percentage of Impairment While Working Because of Health (Mean, SD)	Surveys are took at week 3, 12 and month 6 and 12 during treatment, and month 18, 24, 30 and 36 during follow up.	Effects of therapy on work productivity and activity - Impairment While Working because of health, evaluated using the Work Productivity and Activity Impairment Questionnaire (WPAI-SHP), which defined per protocol.
Number of Patients Have Alopecia	Median follow-up was 3.9 years. The AE data cutoff date is 21 April 2020.	alopecia assessment is a 5-item questionnaire that will assess the impact alopecia has had on these patients and will be conducted electronically at pre-specified study visits. If electronic evaluation is not possible, paper evaluation will be conducted.
Number of SNPs With Top Associations of Trastuzumab Emtansine-induced Grade 2-4 Thrombocytopenia in the T-DM1 Arm	DNA sample collected at pre-treatment. AE is reported every 3 weeks for the first 12 weeks, then every 9 weeks for the subsequent 39 weeks.	DNA will be genotyped for SNPs and CNV markers using the Infinium Human Omni1 array (1.2 million SNP platform) from Illumina. A gene-based association analyses for thrombocytopenia or bleeding is applied with significancy (p-value). This analysis was only conducted in the T-DM1 arm.
Quality of Life (QOL) FACT B Total Score at Baseline	at baseline	The QOL assessments questionnaire should be completed via the tablet provided by the study or on any available computer with an internet connection. The FACT-B questionnaire consists of five subscale, listed below: Physical well being(PWB): range 0-28 Social/Family well being(SWB): range 0-28 Emotional well being(EWB): range 0-24 Functional well being(FWB): range 0-28 Breast cancer subscale(BCS): range 0-40 The total score (FACTB) is calculated by summarizing all the subscales listed above, therefore it ranges from 0 to 148. The higher the score the better the outcome (applies to all sub-scales as well).
Quality of Life (QOL) FACT B Total Score at 18 Months	at 18 months	The QOL assessments questionnaire should be completed via the tablet provided by the study or on any available computer with an internet connection. The FACT-B questionnaire consists of five subscale, listed below: Physical well being(PWB): range 0-28 Social/Family well being(SWB): range 0-28 Emotional well being(EWB): range 0-24 Functional well being(FWB): range 0-28 Breast cancer subscale(BCS): range 0-40 The total score (FACTB) is calculated by summarizing all the subscales listed above, therefore it ranges from 0 to 148. The higher the score the better the outcome (applies to all sub-scales as well).
Incidence Rate of Grade 3-4 Treatment-Related Toxicity	AE is reported every 3 weeks for the first 12 weeks, then every 9 weeks for the subsequent 39 weeks, then follow-up up to 5 years after completion of study treatment or until death, whichever occurs first. Median follow-up 3.1 years.	All grade 3 - 4 adverse events (AE) with treatment attribution of possibly, probably or definite based on CTCAEv4 as reported on case report forms were counted. Incidence is the number of patients experiencing at least one treatment-related grade \>=3 AE of any type during the time of observation.
Quality of Life (QOL) FACT B Total Score at 6 Months	at 6 months	The QOL assessments questionnaire should be completed via the tablet provided by the study or on any available computer with an internet connection. The FACT-B questionnaire consists of five subscale, listed below: Physical well being(PWB): range 0-28 Social/Family well being(SWB): range 0-28 Emotional well being(EWB): range 0-24 Functional well being(FWB): range 0-28 Breast cancer subscale(BCS): range 0-40 The total score (FACTB) is calculated by summarizing all the subscales listed above, therefore it ranges from 0 to 148. The higher the score the better the outcome (applies to all sub-scales as well).
Quality of Life (QOL) FACT B Total Score at Week 3	at week 3	The QOL assessments questionnaire should be completed via the tablet provided by the study or on any available computer with an internet connection. The FACT-B questionnaire consists of five subscale, listed below: Physical well being(PWB): range 0-28 Social/Family well being(SWB): range 0-28 Emotional well being(EWB): range 0-24 Functional well being(FWB): range 0-28 Breast cancer subscale(BCS): range 0-40 The total score (FACTB) is calculated by summarizing all the subscales listed above, therefore it ranges from 0 to 148. The higher the score the better the outcome (applies to all sub-scales as well).
Quality of Life (QOL) FACT B Total Score at 24 Months	at 24 months	The QOL assessments questionnaire should be completed via the tablet provided by the study or on any available computer with an internet connection. The FACT-B questionnaire consists of five subscale, listed below: Physical well being(PWB): range 0-28 Social/Family well being(SWB): range 0-28 Emotional well being(EWB): range 0-24 Functional well being(FWB): range 0-28 Breast cancer subscale(BCS): range 0-40 The total score (FACTB) is calculated by summarizing all the subscales listed above, therefore it ranges from 0 to 148. The higher the score the better the outcome (applies to all sub-scales as well).
Percentage of Work Time Missed Because of Health	Surveys are took at week 3, 12 and month 6 and 12 during treatment, and month 18, 24, 30 and 36 during follow up.	Effects of therapy on work productivity and activity - work time missed because of health, evaluated using the Work Productivity and Activity Impairment Questionnaire (WPAI-SHP), which defined per protocol.
Number of Incidence of T-DM1 Induced Grade 2-3 Thrombocytopenia	AE is reported every 3 weeks for the first 12 weeks, then every 9 weeks for the subsequent 39 weeks, then follow-up up to 5 years after completion of study treatment or until death, whichever occurs first. Median follow-up 3.1 years.	Reversible Grade 1-4 thrombocytopenia has been observed in ongoing studies with trastuzumab emtansine.
Percentage of Patients With Amenorrhea	Surveys are took at month 6 and 12 during treatment, and month 18, 24, 30 and 36 during follow up.	All grade 3 - 4 adverse events (AE) with treatment attribution of possibly, probably or definite based on CTCAEv4 as reported on case report forms were counted. Incidence is the number of patients experiencing at least one treatment-related grade \>=3 AE of any type during the time of observation. For those who were premenopausal pre-chemotherapy, at each follow-up visit (every six months) in order to assess for duration of amenorrhea and also premature ovarian failure.
Percentage of Overall Work Impairment Because of Health	Surveys are took at week 3, 12 and month 6 and 12 during treatment, and month 18, 24, 30 and 36 during follow up.	Effects of therapy on work productivity and activity - Work Impairment because of health, evaluated using the Work Productivity and Activity Impairment Questionnaire (WPAI-SHP), which defined per protocol.
Median Overall Survival (OS)	Reported every 3 weeks for the first 12 weeks, then every 9 weeks for the subsequent 39 weeks, then follow-up up to 5 years after completion of study treatment or until death, whichever occurs first.	OS is evaluated in patients with Stage I HER2-positive breast cancer treated with trastuzumab emtansine
Number of Incidence of Grade 3-4 Cardiac Left Ventricular Dysfunction	AE is reported every 3 weeks for the first 12 weeks, then every 9 weeks for the subsequent 39 weeks, then follow-up up to 5 years after completion of study treatment or until death, whichever occurs first. Median follow-up 3.1 years.	All grade 3 - 4 adverse events (AE) with treatment attribution of possibly, probably or definite based on CTCAEv4 as reported on case report forms were counted. Incidence is the number of patients experiencing at least one treatment-related grade \>=3 AE of any type during the time of observation
Gene Mutation Assessed Using High-throughput Mutation Profiling System (Oncomap)	After treatment	Archival tumor tissue from all patients will be assessed using a high-throughput mutation profiling system (Oncomap) to query a large panel of cancer gene mutations.

Trial Locations

Locations (78): Rex Cancer Center
🇺🇸
Raleigh, North Carolina, United States
Johns Hopkins - Sidney Kimmel Comprehensive Cancer Center
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Baltimore, Maryland, United States
Memorial Sloan Kettering Cancer Center Westchester
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Harrison, New York, United States
UPMC St. Margaret
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Pittsburgh, Pennsylvania, United States
UPMC Cancer Center St. Clair Hospital
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Pittsburgh, Pennsylvania, United States
Baylor College of Medicine-Baylor Clinic
🇺🇸
Houston, Texas, United States
Harris County Hospital District-Ben Taub General Hospital
🇺🇸
Houston, Texas, United States
Harris County Hospital District-Smith Clinic
🇺🇸
Houston, Texas, United States
University of Washington Seattle Cancer Care Alliance
🇺🇸
Seattle, Washington, United States
Indiana University Health - Melvin and Bren Simon Cancer Center
🇺🇸
Indianapolis, Indiana, United States
Indiana University - Springmill Medical Clinic
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Indianapolis, Indiana, United States
Duke University Medical Center
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Durham, North Carolina, United States
William W Backus Hospital
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Norwich, Connecticut, United States
Georgetown Hospital
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Washington, District of Columbia, United States
Sibley Memorial Hospital
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Washington, District of Columbia, United States
Dana-Farber Cancer Insitute at Londonderry Hospital
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Londonderry, New Hampshire, United States
Mountain States Tumor Institute
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Twin Falls, Idaho, United States
Hartford Healthcare Cancer Institute at The Hospital of Central Connecticut
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New Britain, Connecticut, United States
Hartford Hospital
🇺🇸
Hartford, Connecticut, United States
Midstate Medical Center
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Meriden, Connecticut, United States
Memorial Sloan Kettering Cancer Center-Basking Ridge
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Basking Ridge, New Jersey, United States
The Ohio State University
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Columbus, Ohio, United States
University of North Carolina
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Chapel Hill, North Carolina, United States
Washington Cancer Institute at Medstar Washington Hospital Center
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Washington, District of Columbia, United States
Eastern Maine Medical Center's Cancer Care
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Brewer, Maine, United States
MD Anderson Cancer Center
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Houston, Texas, United States
University of Alabama Birmingham
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Birmingham, Alabama, United States
Vanderbilt-Ingram Cancer Center
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Nashville, Tennessee, United States
Suburban Hospital Cancer Program
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Bethesda, Maryland, United States
Mayo Clinic
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Rochester, Minnesota, United States
Univeristy of Michigan Health System
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Ann Arbor, Michigan, United States
University of California San Francisco
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San Francisco, California, United States
Florida Cancer Specialists
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Saint Petersburg, Florida, United States
Indiana University Health - University Hospital
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Indianapolis, Indiana, United States
University of Chicago Medical Center for Advanced Care Orland Park
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Orland Park, Illinois, United States
Loyola University Medical Center
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Maywood, Illinois, United States
University of Chicago Comprehensive Cancer Center at Silver Cross Hospital
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New Lenox, Illinois, United States
Indiana University - Wishard Hospital
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Indianapolis, Indiana, United States
Johns Hopkins - Green Spring Station
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Lutherville, Maryland, United States
Massachusetts General Hospital
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Boston, Massachusetts, United States
Dana Farber Cancer Institute at Faulkner Hospital
🇺🇸
Boston, Massachusetts, United States
Beth Israel Deaconess Medical Center
🇺🇸
Boston, Massachusetts, United States
Dana-Farber Cancer Institute
🇺🇸
Boston, Massachusetts, United States
Mass General North Shore Cancer Center
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Danvers, Massachusetts, United States
Dana-Farber Cancer Institute at Milford Hospital
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Milford, Massachusetts, United States
Lowell General Hospital
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Lowell, Massachusetts, United States
Barnes-Jewish Hospital
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Saint Louis, Missouri, United States
Washington University, School of Medicine
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Saint Louis, Missouri, United States
Siteman Cancer Center - South County
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Saint Louis, Missouri, United States
New Hampshire Oncology-Hematology, PA
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Laconia, New Hampshire, United States
Siteman Cancer Center - St. Peters
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Saint Peters, Missouri, United States
Siteman Cancer Center - West County
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Saint Louis, Missouri, United States
Northwell Health/Monter Cancer Center
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Lake Success, New York, United States
Memorial Sloan Kettering Cancer Center-Suffolk
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Commack, New York, United States
Queens Hospital Center, Comprehensive Cancer Center
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Jamaica, New York, United States
Memorial Sloan Kettering Cancer Center
🇺🇸
New York, New York, United States
Memorial Sloan Kettering Cancer Center-Mercy
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Rockville Centre, New York, United States
Lehigh Valley Hospital/Lehigh Valley Health Network
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Allentown, Pennsylvania, United States
UPMC/HVHS Cancer Center, UPMC Beaver
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Beaver, Pennsylvania, United States
UPMC CancerCenters Butler
🇺🇸
Butler, Pennsylvania, United States
UPMC Horizon (Shenango)
🇺🇸
Farrell, Pennsylvania, United States
Arnold Palmer Cancer Center-Greensburg
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Greensburg, Pennsylvania, United States
UPMC Pinnacle Harrisburg
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Harrisburg, Pennsylvania, United States
UPMC Horizon (Greenville)
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Greenville, Pennsylvania, United States
UPMC Cancer Center Jefferson Regional Med Ctr
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Jefferson Hills, Pennsylvania, United States
UPMC Conemaugh Cancer Center
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Johnstown, Pennsylvania, United States
UPMC East
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Monroeville, Pennsylvania, United States
UPMC McKeesport
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McKeesport, Pennsylvania, United States
Arnold Palmer Medical Oncology-Mt Pleasant
🇺🇸
Mount Pleasant, Pennsylvania, United States
UPMC Jameson Cancer Center
🇺🇸
New Castle, Pennsylvania, United States
UPMC Northwest (Franklin)
🇺🇸
Seneca, Pennsylvania, United States
UPMC Presbyterian Shadyside
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Pittsburgh, Pennsylvania, United States
UPMC Passavant
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Pittsburgh, Pennsylvania, United States
UPMC Northwest (Oil City)
🇺🇸
Seneca, Pennsylvania, United States
UPMC and the Washington Hospital Center
🇺🇸
Washington, Pennsylvania, United States
Tennessee Oncology/Sarah Cannon Research Institute
🇺🇸
Nashville, Tennessee, United States
Memorial Sloan Kettering Cancer Center-Sleepy Hollow
🇺🇸
Sleepy Hollow, New York, United States
Arnold Palmer Medical Oncology Oakbrook
🇺🇸
Greensburg, Pennsylvania, United States