POSITIVE: Pregnancy Outcome and Safety of Interrupting Therapy for Women With Endocrine Responsive Breast Cancer

Sponsor

ETOP IBCSG Partners Foundation (Other)

Overall Status

Active, not recruiting

CT.gov ID

NCT02308085

Collaborator

Alliance for Clinical Trials in Oncology (Other), Canadian Cancer Trials Group (Other), Breast International Group (Other)

518

Enrollment

211

Locations

Arm

167.9

Anticipated Duration (Months)

2.5

Patients Per Site

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

The best available evidence suggests that pregnancy after breast cancer does not increase a woman's risk of developing a recurrence from her breast cancer. In particular, the most recent data suggest that this is the case also in women with a hormone receptor-positive breast cancer. There is also no indication of increased risk for delivery complications or for the newborn. The aim of the study is to investigate if temporary interruption of endocrine therapy, with the goal to permit pregnancy, is associated with a higher risk of breast cancer recurrence.The study aims also to evaluate different specific indicators related to fertility, pregnancy and breast cancer biology in young women. A psycho-oncological companion study on fertility concerns, psychological well-being and decisional conflicts will be conducted in interested Centers.

Condition or Disease	Intervention/Treatment	Phase
Early Breast Cancer	Other: Endocrine therapy interruption	N/A

Detailed Description

Recent decades have witnessed a delay in childbearing for a variety of reasons including cultural, educational, and professional. As a consequence, breast cancer in young women often occurs before the completion of reproductive plans. Infertility has a significant impact on quality of life, resulting in substantial distress in younger women with breast cancer and influencing treatment decisions in a consistent proportion of patients.The best available evidence suggests that pregnancy after breast cancer does not increase a woman's risk of developing a recurrence.For women desiring pregnancy after a breast cancer, 5-10 years of endocrine therapy may substantially reduce the chance of conception; however, a shorter duration of endocrine therapy in this population has not been studied in a prospective manner.

Birth outcome after breast cancer has not been shown to be different from that of the normal population, but increased risks of delivery complications, cesarean section, preterm birth and low birth weight have been reported.

Endocrine agents are potentially teratogenic: taking into account their median half-life, waiting 3 months after their interruption before attempting conception is considered safe.

The limited evidence available on breastfeeding after breast cancer reports successful lactation from the treated breast in approximately 30% of women without detrimental effect on survival. No prospective definitive data are available.

Study Design

Study Type:

Interventional

Actual Enrollment :

518 participants

Allocation:

N/A

Intervention Model:

Single Group Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

A Study Evaluating the Pregnancy Outcomes and Safety of Interrupting Endocrine Therapy for Young Women With Endocrine Responsive Breast Cancer Who Desire Pregnancy

Actual Study Start Date :

Dec 4, 2014

Anticipated Primary Completion Date :

Dec 1, 2022

Anticipated Study Completion Date :

Dec 1, 2028

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Endocrine therapy interruption Endocrine therapy interruption after having completed between ≥ 18 months and ≤ 30 months.	Other: Endocrine therapy interruption 3 months wash-out between treatment interruption and pregnancy attempt. Up to 2 years interruption to allow pregnancy, delivery, breastfeeding or failure to conceive. Endocrine therapy resumption. Completion of full duration of endocrine therapy according to individual risk, institutional policy or patient's preference.

Arm

Intervention/Treatment

Experimental: Endocrine therapy interruption

Endocrine therapy interruption after having completed between ≥ 18 months and ≤ 30 months.

Other: Endocrine therapy interruption

3 months wash-out between treatment interruption and pregnancy attempt. Up to 2 years interruption to allow pregnancy, delivery, breastfeeding or failure to conceive. Endocrine therapy resumption. Completion of full duration of endocrine therapy according to individual risk, institutional policy or patient's preference.

Outcome Measures

Primary Outcome Measures

Breast Cancer free interval (BCFI) [From enrollment until the first invasive BC event, assessed up to 14 years]
Kaplan-Meier Analysis

Secondary Outcome Measures

Information on Menstruation recovery and pattern [Up to 24 months after enrollment]
Menstrual diary
Pregnancy rate (determined by pregnancy test) [Up to 24 months after enrollment]
Pregnancy test
Pregnancy outcome [Up to 33 months after enrollment]
Labor and delivery Information, full term pregnancy, caesarean section, abortion, miscarriage, ectopic, stillbirth rates.
Offspring outcome [Up to 33 months after enrollment]
Collect information on preterm birth, low birth weight, births defects rates.
Breastfeeding pattern [Up to 36 months after enrollment]
Analysis of pattern e.g Duration, use of ipsilateral breast if previous breast conservation, side exclusivity
Use of assisted reproductive Technology (ART) [Up to 24 months after enrollment]
ART use will be tabulated
Distant recurrence-free interval (DRFI) [Time from enrollment in the study to the first breast cancer recurrence in a distant site, assessed up to 14 years]
Kaplan-Meier Analysis

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years to 42 Years

Sexes Eligible for Study:

Female

Accepts Healthy Volunteers:

Inclusion Criteria:

Age ≥ 18 and ≤ 42 years at enrollment.
Has received adjuvant endocrine therapy (SERM alone, GnRH analogue plus SERM or AI) for ≥18 months but ≤30 months for early breast cancer.

Note: Patients who have received neo/adjuvant endocrine treatment within a clinical trial and patients who have received pharmaco-prevention are eligible.

The adjuvant endocrine therapy must have stopped within 1 month prior to enrollment.
Patient wishes to become pregnant. Note: Patients who have undergone oocyte/embryo/ovarian tissue cryopreservation at breast cancer diagnosis and/or have a previous history of assisted reproductive technology (ART) are eligible.
Breast cancer for which patient is receiving endocrine therapy must have been histologically-proven stage I-III, endocrine-responsive (i.e., estrogen and/or progesterone receptor positive, according to local definition of positive, determined using immunohistochemistry (IHC)), and treated with curative intent.

Note:

Patients with synchronous bilateral invasive breast cancer (diagnosed histologically within 2 months) are eligible.
Patient with invasive breast cancer or synchronous bilateral invasive breast cancer (diagnosed histologically within 2 months) during pregnancy are eligible.
Patients with BRCA1/2 mutations are eligible.
Patients could have received neo/adjuvant chemotherapy, or other systemic therapy (e.g., neo/adjuvant HER2-targeted therapy) according to institutional policy and patient's desire.
Patient must be premenopausal at breast cancer diagnosis, as determined locally and documented in patient record.
Patient must be without clinical evidence of loco-regional and distant disease, as evaluated according to institutional assessment standards and documented in the patient record.
Written informed consent (IC) for trial participation must be signed and dated by the patient and the investigator prior to enrollment.
Written consent to biological material submission, indicating the patient has been informed of and agrees to tissue and blood material use, transfer and handling, must be signed and dated by the patient and the investigator prior to any procedures specific for this trial.
The patient has been informed of and agrees to data transfer and handling, in accordance with national data protection guidelines.
Patient must be accessible for follow-up.

Exclusion Criteria:

Post-menopausal patients at BC diagnosis, as determined locally.
History of hysterectomy, bilateral oophorectomy or ovarian irradiation.
Patients with current local, loco-regional relapse and/or distant metastatic breast cancer.
Patients with a history of prior (ipsi- and/or contralateral) invasive BC.
Patients with previous or concomitant non-breast invasive malignancy.
Exceptions are limited exclusively to patients with the following previous malignancies, if adequately treated: basal or squamous cell carcinoma of the skin, in situ non-breast carcinoma, contra- or ipsilateral in situ breast carcinoma, stage Ia carcinoma of the cervix.
Concurrent disease or condition that would make the patient inappropriate for study participation or any serious medical disorder that would interfere with the patient's safety.
Patients with a history of noncompliance to medical treatments and/or considered potentially unreliable.
Patients with psychiatric, addictive, or any disorder that would prevent compliance with protocol requirements.

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	Cedars Sinai Medical Centre	Los Angeles	California	United States	90211
2	Stanford Cancer Institute	Palo Alto	California	United States	94305
3	Sharp Memorial Hospital	San Diego	California	United States
4	University of Colorado Cancer Centre - Anschutz Cancer Pavilion	Aurora	Colorado	United States	80045
5	Rocky Mountain Cancer Center	Boulder	Colorado	United States	80303
6	SCL Health Saint Joseph Hospital	Denver	Colorado	United States	80218
7	Poudre Valley Hospital	Fort Collins	Colorado	United States	80524
8	Smilow Cancer Hospital-Derby Care Center	Derby	Connecticut	United States	06418
9	Smilow Cancer Hospital Care Center-Fairfield	Fairfield	Connecticut	United States	06824
10	Smilow Cancer Hospital Care Center at Saint Francis	Hartford	Connecticut	United States	06105
11	Yale University - Yale Cancer Centre	New Haven	Connecticut	United States	06520
12	Yale-New Haven Hospital North Haven Medical Center	North Haven	Connecticut	United States	06473
13	Smilow Cancer Hospital-Orange Care Center	Orange	Connecticut	United States	06477
14	Smilow Cancer Hospital-Torrington Care Center	Torrington	Connecticut	United States	06790
15	Smilow Cancer Hospital Care Center-Trumbull	Trumbull	Connecticut	United States	06611
16	Smilow Cancer Hospital-Waterbury Care Center	Waterbury	Connecticut	United States	06708
17	Helen F. Graham Cancer Center	Newark	Delaware	United States	19713
18	Christiana Care Health System-Christiana Hospital	Newark	Delaware	United States	19718
19	Medical Oncology Hematology Consultants PA	Newport	Delaware	United States	19713
20	Regional Hematology Oncology Practice Associates	Newport	Delaware	United States	19713
21	Georgetown University Hospital	Washington	District of Columbia	United States	20007
22	Sibley Memorial Hospital	Washington	District of Columbia	United States	20016
23	Emory University Hospital Midtown	Atlanta	Georgia	United States	30308
24	Emory University	Atlanta	Georgia	United States	30322
25	Straub Clinic and Hospital	Honolulu	Hawaii	United States	96701
26	OnCare Hawaii Inc - POB I	Honolulu	Hawaii	United States	96813
27	Queen's Medical Centre	Honolulu	Hawaii	United States	96813
28	OnCare Hawaii-Kuakini	Honolulu	Hawaii	United States	96817
29	John H Stroger Jr Hospital of Cook County	Chicago	Illinois	United States	60612
30	Carle on Vermilion	Danville	Illinois	United States	61832
31	Carle Physician Group - Effingham	Effingham	Illinois	United States	62401
32	NorthShore University HealthSystem-Evanston Hospital	Evanston	Illinois	United States	60201
33	Northwestern University	Evanston	Illinois	United States	60201
34	NorthShore University Health System - Glenbrook Hospital	Glenview	Illinois	United States	60026
35	NorthShore Unversity Health System - Highland Park Hospital	Highland Park	Illinois	United States	60035
36	Mattoon Charleston Primary Care	Mattoon	Illinois	United States	61938
37	NorthShore Medical Centre	Skokie	Illinois	United States	60076
38	Carle Cancer Centre	Urbana	Illinois	United States	61801
39	The Carle Foundation Hospital	Urbana	Illinois	United States	61801
40	Indiana University	Indianapolis	Indiana	United States	46202
41	Greater Baltimore Medical Centre	Baltimore	Maryland	United States	21204
42	Johns Hopkins University	Baltimore	Maryland	United States	21218
43	Dana Farber Cancer Institute	Boston	Massachusetts	United States	02215-5450
44	Saint Joseph Mercy Hospital	Ann Arbor	Michigan	United States	48103
45	IHA Hematology Consultants-Brighton	Brighton	Michigan	United States	48114
46	Saint Joseph Mercy Hospital - Brighton	Brighton	Michigan	United States	48114
47	IHA Hematology Consultants-Canton	Canton	Michigan	United States	48188
48	Saint Joseph Mercy Hospital- Canton	Canton	Michigan	United States	48188
49	IHA Hematology Consultants-Chelsea	Chelsea	Michigan	United States	48118
50	Saint Joseph Mercy Hospital - Chelsea	Chelsea	Michigan	United States	48118
51	IHA Hematology Oncology Consultants-Ann Arbor	Ypsilanti	Michigan	United States	48198
52	Sanford Clinic North - Bemidji	Bemidji	Minnesota	United States	56501
53	Mercy Hospital	Coon Rapids	Minnesota	United States	55433
54	Essentia Health Cancer Center	Duluth	Minnesota	United States	55805-1951
55	Fairview Southdale Hospital	Edina	Minnesota	United States	55435
56	St John's Hospital	Maplewood	Minnesota	United States	55109
57	Abbott-Northwestern Hospital, 800 East 28th Street	Minneapolis	Minnesota	United States	55407
58	Hennepin County Medical Center - Cancer Center	Minneapolis	Minnesota	United States	55415
59	Mayo Clinic	Rochester	Minnesota	United States	55902
60	Park Nicollet Methodist Hospital	Saint Louis Park	Minnesota	United States	55343
61	Regions Hospital	Saint Paul	Minnesota	United States	55101
62	Missouri Baptist Medical Center	Saint Louis	Missouri	United States	63131
63	Bozeman Deaconess Hospital	Bozeman	Montana	United States	59715
64	Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center	Lebanon	New Hampshire	United States	03756
65	University of New Mexico Cancer Center	Albuquerque	New Mexico	United States	87131
66	Montefiore Medical Center - Einstein Campus, 1695 Eastchester Road	Bronx	New York	United States	10461
67	Montefiore Medical Center-Weiler Hospital	Bronx	New York	United States	10461
68	Montefiore Medical Center - Moses Campus, 111 East 210th Street	Bronx	New York	United States	10467
69	Weill Medical College of Cornell University	New York	New York	United States	10065
70	SUNY Upstate Medical University	Syracuse	New York	United States	13210
71	Dickstein Cancer Treatment Centre	White Plains	New York	United States	10601
72	UNC Lineberger Comprehensive Cancer Center	Chapel Hill	North Carolina	United States	27599
73	Southeastern Medical Oncology Centre	Clinton	North Carolina	United States	28328
74	Southeastern Medical Oncology Centre	Goldsboro	North Carolina	United States	27534
75	Margaret R Pardee Memorial Hospital	Hendersonville	North Carolina	United States
76	Southeastern Medical Oncology Centre	Jacksonville	North Carolina	United States	28546
77	Southeastern Medical Oncology Centre	Wilson	North Carolina	United States	27534
78	Sanford Bismark Medical Centre	Bismarck	North Dakota	United States	58501
79	Sanford Roger Maris Cancer Centre	Fargo	North Dakota	United States	58102
80	Sanford Medical Centre	Fargo	North Dakota	United States	58122
81	Case Western Reserve University	Cleveland	Ohio	United States	44106
82	Ohio State University	Columbus	Ohio	United States	43210
83	Chagrin Highlands	Orange Village	Ohio	United States	44122
84	UPMC-Magee Womens Hospital	Pittsburgh	Pennsylvania	United States	15213
85	Women and Infants Hospital of Rhode Island	Providence	Rhode Island	United States	02905
86	Greenville Health System Cancer Institute-Butternut	Greenville	South Carolina	United States	29605
87	Greenville Health System Cancer Institute-Faris	Greenville	South Carolina	United States	29605
88	Greenville Health System Cancer Institute-Eastside	Greenville	South Carolina	United States	29611
89	Greenville Health System Cancer Institute-Greer	Greer	South Carolina	United States	29650
90	Greenville Health System Cancer Institute-Seneca	Seneca	South Carolina	United States	29672
91	Spartanburg Medical Center	Spartanburg	South Carolina	United States	29303
92	Greenville Health System Cancer Institute-Spartanburg	Spartanburg	South Carolina	United States	29307
93	Sanford Cancer Centre Oncology Clinic	Sioux Falls	South Dakota	United States	57104
94	Sanford USD Medical Centre - Sioux Falls	Sioux Falls	South Dakota	United States	57104
95	Doctor's Hospital of Laredo	Laredo	Texas	United States	78045
96	Huntsman Cancer Institute / University of Utah	Salt Lake City	Utah	United States	84112
97	University of Vermont Medical Centre	Burlington	Vermont	United States	05401
98	Bon Secours Memorial Regional Medical Centre	Mechanicsville	Virginia	United States	23116
99	Bon Secours Saint Francis Medical Centre	Midlothian	Virginia	United States	23114
100	Bon Secours Saint Mary's Hospital	Richmond	Virginia	United States	23223
101	Fred Hutchinson Cancer Research Center	Seattle	Washington	United States	98109
102	Seattle Cancer Care Alliance	Seattle	Washington	United States	98109
103	University of Washington Medical Center	Seattle	Washington	United States	98195
104	St John of God Subiaco Hospital	Perth	Western Australia	Australia	6008
105	Univ. Klinik f. Frauenheilkunde u. Geburtshilfe	Graz		Austria	8036
106	Univ. Klinik f. Frauenheilkunde Innsbruck	Innsbruck		Austria	6020
107	LKH Salzburg	Salzburg		Austria	5020
108	Med. Univ. Klinik f. Chir	Vienna		Austria	1090
109	Cliniques Universitaires Saint-Luc	Brussels		Belgium	1200
110	Cliniques Universitaires Saint-Luc Brussels	Brussels		Belgium
111	Institut Jules Bordet	Brussels		Belgium
112	UZ Leuven	Leuven		Belgium	3000
113	C.H.U. Sart-Tilman	Liege		Belgium	4000
114	Clinique St.Elizabeth	Namur		Belgium	5000
115	Tom Baker Cancer Centre	Calgary	Alberta	Canada	T2N 4N2
116	Vancouver Cancer Centre	Vancouver	British Columbia	Canada	V5Z 1M9
117	St Michael's Hospital	Toronto	Ontario	Canada	M5B 1W8
118	Mount Sinai Hospital	Toronto	Ontario	Canada	M5G 1X5
119	Odette Cancer Centre - Sunnybrook Health Sciences Centre	Toronto	Ontario	Canada
120	CHUM - Centre Hospitalier de l'Universite de Montreal	Montréal	Quebec	Canada	H2X 3E4
121	CHA-Hopital Du St-Sacrement	Quebec City	Quebec	Canada	G1S 4L8
122	Centre Hospitalier Universitaire de Sherbrooke	Sherbrooke	Quebec	Canada
123	Rigshospitalet	København		Denmark	2100
124	Institut Bergonie	Bordeaux		France	33076
125	Centre Oscar Lambret	Lille		France	59020
126	French Lyon Cancer Center	Lyon		France	69373
127	APHP, Tenon Hospital in Paris	Paris		France
128	University General Hospital of Heraklion	Stavrakia	Crete	Greece	71110
129	Laso General Hospital, First Department of Medical Oncology	Athens		Greece
130	Debrecen University Dep. of Oncology	Debrecen		Hungary
131	St. James's Hospital	Dublin 8		Ireland
132	St Vincent's University Hospital	Dublin		Ireland
133	Galway University Hospital	Galway		Ireland
134	University Hospital Limerick	Limerick		Ireland
135	University Hospital Waterford	Waterford		Ireland
136	Shaare Zedek Medical Center	Jerusalem		Israel
137	Chaim Sheba Medical Center	Tel Hashomer		Israel	5265601
138	Ospedale di Prato	Prato	Firenze	Italy
139	U.O Medicina Oncologica Ospedale di Carpi	Carpi	Modena	Italy	41012
140	Multimedica Spa	Castellanza	Vareze	Italy
141	Centro di Riferimento Oncologico	Aviano		Italy	33081
142	Ospedale degli Infermi - S. C. Oncologia Medica	Biella		Italy
143	Azienda Sanitaria di Bolzano	Bolzano		Italy	39100
144	Istituto Nazionale Ricerca Cancro	Genova		Italy
145	Istituto scientifico Romagnolo per lo studio e la cura	Meldola		Italy
146	Istituto Europeo di Oncologia (IEO)	Milan		Italy	20141
147	University of Eastern Piedmont	Novara		Italy	28100
148	Salvatore Maugeri Foundation - Medical Oncology Unit	Pavia		Italy	27100
149	UO Oncologia, Rimini Hospital	Rimini		Italy	47923
150	Regina Elena National Cancer Institute	Rome		Italy
151	Ospedale di Trento	Trento		Italy	38122
152	AO Universitaria Ospedale Di Circolo e Fondazione	Varese		Italy	21100
153	Ospedale Belcolle di Viterbo	Viterbo		Italy
154	Kansai Rosai Hospital	Amagasaki	Hyogo	Japan	660-8511
155	Seirei Hamamatsu General Hospital	Hamamatsu	Shizuoka	Japan
156	NHO Kyushu Cancer Centre, 3-1-1 Notame Minami-ku Fukuoka-shi	Fukuoka		Japan	811-1395
157	Social Medical Corporation Hakuaikai Sagara Hospital	Kagoshima		Japan
158	St Marianna University School of Medicine Hospital	Kawasaki		Japan
159	Kyoto University Hospital	Kyoto		Japan
160	NHO Shikoku Cancer Center	Matsuyama		Japan
161	Toranomon Hospital	Minato-ku, Tokyo		Japan	105-8470
162	Kamiiida Daiichi General Hospital	Nagoya		Japan	463-0802
163	Okayama University Hospital	Okayama		Japan
164	Tohoku University Hospital	Sendai		Japan
165	National Cancer Center for Global Medicine	Tokyo		Japan
166	National Cancer Center Hospital	Tokyo		Japan
167	Showa University Hospital	Tokyo		Japan
168	St Luke's International Hospital	Tokyo		Japan
169	The Cancer Institute Hospital of JFCR	Tokyo		Japan
170	University of Tsukuba	Tsukuba		Japan
171	NHO Osaka National Hospital	Ōsaka		Japan
172	Samsung Medical Center	Seoul		Korea, Republic of	06351
173	Asan Medical Center	Seoul		Korea, Republic of
174	Seoul National University Hospital	Seoul		Korea, Republic of
175	American University of Beirut Medical Center	Beirut		Lebanon
176	Leiden University Medical Centre, Albinusdreef 2, Postbus 9600	Leiden		Netherlands	2300 RC
177	Norwegian Radium Hospital (Oslo University)	Oslo		Norway
178	Champalimaud Cancer Center - Breast Cancer Unit	Lisbon		Portugal
179	Institute of Oncology & Radiology of Serbia	Belgrade		Serbia
180	Institute of Oncology Ljubljana - Medical Oncology Department	Ljubljana		Slovenia
181	Hospital Clinico Universitario Virgen de la Arrixaca	El Palmar	Murcia	Spain
182	Hospital Universitario Vall d'Hebron	Barcelona		Spain	08035
183	Hospital General de Catalunya	Barcelona		Spain
184	Hospital Universitario Donostia	Donostia		Spain
185	Instituto Catalán de Oncología de Gerona Hospital	Gerona		Spain
186	Hospital Universitario HM Sanchinarro - Centro Integral Oncologico Clara Campal (CIOCC)	Madrid		Spain	28050
187	Hospital Clinico San Carlos	Madrid		Spain
188	Hospital Universitario de Fuenlabrada	Madrid		Spain
189	Hospital Clinico Universitario Virgen de la Victoria	Málaga		Spain	29010
190	Hospital Universitario Central de Asturias	Oviedo		Spain
191	Hospital Son Espases, Palma de Mallorca	Palma		Spain
192	Complejo Hospitalario de Navarra	Pamplona		Spain
193	Complejo Hospitalario Universitario de Santiago	Santiago de Compostela		Spain
194	Universitario Virgen del Rocio	Sevilla		Spain	41013
195	Hospital Quiron Sagrado Corazon	Sevilla		Spain
196	Hospital Virgen De La Salud	Toledo		Spain
197	Hospital General Universitario de Valencia - Servico Oncologia	Valencia		Spain
198	Hospital Clinico Universitario Lozano Blesa	Zaragoza		Spain
199	Spital STS AG Onkologiezentrum Thun-Berner Oberland	Thun	Bern	Switzerland	3600
200	Kantonspital Baden AG	Baden		Switzerland	5404
201	Universitätsspital Basel	Basel		Switzerland	4031
202	Istituto Oncologico della Svizzera Italiana (IOSI)	Bellinzona		Switzerland
203	Inselspital Bern	Bern		Switzerland	3010
204	Oncocare Bern	Bern		Switzerland	3012
205	Brustzentrum Thurgau - Obstetrics and Gynecology	Frauenfeld		Switzerland
206	University Hospital Geneva	Genève		Switzerland	1211
207	University Hospital of Lausanne (CHUV) BH06 - Oncology Department	Lausanne		Switzerland
208	CHCVs Hôpital de Sion - Service d'oncologie ambulatoire	Sion		Switzerland	736
209	Brustzentum Kantonsspital St. Gallen	St. Gallen		Switzerland	9007
210	University Hospital Zurich	Zurich		Switzerland	8091
211	Brust-Zentrum AG	Zürich		Switzerland	8008