Workplace Safety and Health Topics

NIOSH

OCCUPATIONAL EXPOSURE TO ANTINEOPLASTIC AGENTS

Recent Publications, Guidelines, Review Articles and Surveys

Muti-channel infusion pump for delivery of chemotherapy and needle and syringe

Recent Publications

This section includes articles published on this topic during the past three years.

Albin K. Administering chemotherapy: Is it safe for pregnant or breast-feeding veterinary technicians? Vet Tech. Oct 2010; E1-E5.

Bigelow S, Schulz H, Dobish R and Chambers CR. Antineoplastic agent workplace contamination study: the Alberta Cancer Board Pharmacy perspective Phase III. J Oncol Pharm Practice. 2009; 15:157-160.

Boccellino M, Pedata P, Castiglia L, La Porta R, Pieri M, Quagliuolo L, Acampora A, Sannolo N and Miraglia N. Doxorubicin can penetrate nitrile gloves and induces apoptosis in keratinocytes cell lines. Toxicol Lett. 2010; 197:61-68.

Bouraoui S, Brahem A, Tabka F, Mrizek N, Saad A and Elghezal H. Assessment of chromosomal aberrations, micronuclei and proliferation rate index in peripheral lymphocytes from Tunisian nurses handling cytotoxic drugs. Environ Toxicol Pharmacol. 2011; 31:250-257.

Boughattas AB, Bouraoui S, Debbabi F, El Ghazel H, Saad A and Mrizak N. Genotoxic risk assessment of nurses handling antineoplastic drugs. Ann Biol Clin (Paris). 2010; 68:545-553.

Buchanan EC and Schneider PJ. Compounding Sterile Preparations, 3rd Ed., 2009.

Cavallo D, Ursini CL, Rondinone B and Iavicoli S. Evaluation of a suitable DNA damage biomarker for human biomonitoring of exposed workers. Environ Mol Mutagen. 2009; 50:781-790.

Chaffee BW, Armistead JA, Benjamin BE, Cotugno MC, Forrey RA, Hintzen BL, Pfeiffenberger T and Stevenson JG. Guidelines for the safe handling of hazardous drugs: consensus recommendations. Am J Health-Syst Pharm. 2010; 67:1545-1546.

Chu WC, Hon C-Y, Danyluk Q, Chua PPS and Astrakianakis G. Pilot assessment of the antineoplastic drug contamination levels in British Columbia hospitals pre- and post-cleaning. J Oncol Pharm Practice. (Published on line 2011; DOI: 10.1177/1078155211402106).

Connor TH, DeBord G, Pretty JR, Oliver MS, Roth TS, Lees PSJ, Krieg EF, Rogers B, Escalante CP, Toennis CA, Clark JC, Johnson B and McDiarmid MA. Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers. J Occup Environ Med. 2010; 52:1019-1027.

Connor TH and MacKenzie BM. Should monoclonal antibodies and their conjugates be considered occupational hazards. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu.

Constantinidis TC, Vagka E, Dallidou P, Basta P, Drakopoulos V, Kakolyris S and Chatzaki E. Occupational health and safety of personnel handling chemotherapeutic agents in Greek hospitals. Eur J Cancer Care. 2011; 20:123-131.

Davis J, McLauchlan R and Connor TH. Exposure to hazardous drugs in healthcare: an issue that will not go away. J Oncol Pharm Practice. 2011; 17:9-13.

Dolezalova L, Odraska P, Gorna L, Prudilova M, Vejpustkova R and Blaha L. Evaporation of selected cytotoxic drugs and permeation of protective gloves - research into the occupational risks of health care personnel handling hazardous cytotoxic drugs (CYTO project). Klin Onkol. 2009; 22:218-222.

Eisenberg, S. Safe handling and administration of antineoplastic chemotherapy. J Infus Nurs. 2009; 32:23-32.

Fabrizi G, Fioretti M, Rocca LM and Curini R. DESI-MS2: a rapid and innovative method for trace analysis of six cytostatic drugs in health care setting. Anal Bioanal Chem. 2011; December 27 (Epub ahead of printing) DOI:10.1007/s00216-011-5626-7.

Forges F, Simoens X and Chauvin F. Comparative parallel assessment of a transfer device in reducing 5-fluorouracil environmental contamination inside positive air pressure isolators. J Oncol Pharm Practice. 2011; 17:61-67.

Friese CR, Himes-Ferris L, Fraier MN, McCullagh MC and Griggs JJ. Structures and processes of care in ambulatory oncology settings and nurse-reported exposure to chemotherapy. BMJ Qual Saf., (Epub ahead of printing) doi:10.1136/bmjqs-2011-000178, August 16, 2011.

Furlow B. How to improve the safety of chemotherapy administration. Oncol Nurse Advisor. 2010; 21-25.

Green E, Johnston M, Trudeau M, Schwartz L, Poirier S, Macartney G and Milliken D. Safe handling of parenteral cytotoxics: Recommendations for Ontario. J Oncol Practice. 2009; 5:1-5.

Gonzalez R, Massoomi F. Manufacturers' recommendations for handling spilled hazardous drugs. Am J Health-Syst Pharm. 2010; 67:1985-1986.

Gulten T, Evke E, Ercan I, Evrensel T, Kurt E and Manavoglu O. Lack of genotoxicity in medical oncology nurses handling antineoplastic drugs: effect of work environment and protective equipment. Work. 2011; 39:485-489.

Halsen G and Kramer I. Assessing the risk to health care staff from long-term exposure to anticancer drugs - the case of monoclonal antibodies. J Oncol Pharm Practice. 2011; 17:68-80.

Hama K, Kitada N, Fukushima K, Hashida T and Kataoka K. Investigation on residual-related error and the effect of solution properties using protective devices for the reconstitution of cytotoxic agents in actual situations. J Oncol Pharm Practice. 2011; 17:55-60.

Hon C-Y, Teschke K, Chua P, Venners S and Nakashima L. Occupational exposure to antineoplastic drugs: Identification of job categories potentially exposed throughout the hospital medication system. Saf Health Work. 2011; 2:273-281.

Hoppe-Tichy T. Current challenges in European oncology pharmacy practice. J Oncol Pharm Pract. 2010; 16:9-18.

Ishiwata S, Taga A, Sano H, Kobayashi M, Nomiyama J, Harada S, Kita A, Takada M and Sugiura R. Evaluation of brilliance and visibility of fluorescence and chemiluminescence solution for training of preparing injections. Yakugaku Zasshi. 2011; 131:1361-1367 (Japanese).

Izdes S, Sardas S, Kadioglu E, Kaymak C and Ozcagli E. Assessment of genotoxic damage in nurses occupationally exposed to anesthetic gases or antineoplastic drugs by the comet assay. J Occup Health. 2009; 51:283-286.

Jacobson JO, Polovich M, McNiff KK, LeFebvre KB, Cummings C, Galioto M, Bonelli KR and McCorkle MR. American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards. J Clin Oncol. 2009; 27:5469-5475.

Kopp B, Schierl R and Nowak D. Evaluation of working practices and surface contamination with antineoplastic drugs in outpatient oncology health care settings. Int Arch Occup Environ Health. (Published on line February 2012; DOI 10.1007/s00420-012-0742-z).

Kopjar N, Garaj-Vrhovac V, Kašuba V, Rozgaj R, Ramić S, Pavlica V and Želježić D. Assessment of genotoxic risks in Croatian health care workers occupationally exposed to cytotoxic drugs: A multi-biomarker approach. Int J Hyg Environ Health. 2009; 212:414-431.

Kyprianou M, Kapsou M, Raftopoulos V and Soteriades ES. Knowledge, attitudes and beliefs of Cypriot nurses on the handling of antineoplastic agents. Eur J Oncol Nurs. 2010; 14:278-282.

Lawson CC, Whelan EA, Hibert EN, Grajewski B, Spiegelman D and Rich-Edwards JW. Occupational factors and risk of preterm birth in nurses. Am J Obstet Gynecol. 2009; 200:51.e1-51.e8.

Lawson CC, Rocheleau CM, Whelan EA, Lividoti Hibert E, Grajewski B, Spiegelman D and Rich-Edwards JW. Occupational exposures among nurses and risk of spontaneous abortion. Am J Obstet Gynecol. 2012; 206:327.e1-8.

Maeda S, Miyawaki K, Matsumoto S, Oishi M, Miwa Y and Kurokawa N. Evaluation of environmental contaminations and occupational exposures involved in preparation of chemotherapeutic drugs. Yakugaku Zasshi. 2010; 130:903-910.

Mahmoud S, Leonard D and Jacklin A. Cytotoxics preparation: reduction of medication errors and enhancing capacity. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu.

McDiarmid MA, Oliver MS, Roth TS, Rogers B. and Escalante CP. Chromosome 5 and 7 abnormalities in oncology personnel handling anticancer drugs. J Occup Environ Med. 2010; 52:1028-1034.

McLauchlan R. Safe dispensing of oral chemotherapy. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu.

Meier K, Griffith N, Chen B, Chuk K, Daouphars M, Doreau C, Patel RA, Schwartz R, Tames MJ, Terkola R, Vadnais, B, Wright D and Goodin S. Safe handling of oral chemotherapeutic agents: a European perspective. Eur J Oncol Pharm. 2011/2; 5:4-10.

Mellinger E, Skinker L, Sears D, Gardner D and Shult P. Safe handling of chemotherapy in the perioperative setting. AORN J. 2010; 91:435- 453.

Meyer HW and Skov PS. Occupational rhinosinusitis due to etoposide, an antineoplastic agent. Scand J Work Environ Health. 2010; 36:266-267.

Ndaw S, Denis F, Marsan P, d'Almedia A and Robert A. Biological monitoring of occupational exposure to 5-fluorouracil: urinary α-fluoro-β-alanine assay by high performance liquid chromatography tandem mass spectrometry in health care personnel. J Chromatog B. 2010; 878:2630-2634.

NIOSH: Workplace Solutions: Safe Handling of Hazardous Drugs for Veterinary Healthcare Workers. DHHS (NIOSH) Publication No. 2010-150 (June 2010).

Nixon S and Schulmeister L. Safe handling of hazardous drugs: Are you protected? Clin J Onc Nurs. 2009; 13:433-439.

Nussbaumer S, Bonnabry P, Veuthey JL and Fleury-Souverain S. Analysis of anticancer drugs: a review. Talanta. 2011; 85:2265-2289.

Nygren O, Olofsson E and Johannson L. NIOSH definition of closed-system transfer devices (Letter to the Editor). Ann Occup Hyg. 2009; 53:549.

Odraska P, Dolezalova L, Piler P, Oravec M and Blaha L. Utilization of the solid sorbent media in monitoring of airborne cyclophosphamide concentrations and the implications for occupational hygiene. J Environ Monit. 2011; 13:1480-1487.

Pieri M, Castiglia L, Basilicata P, Sannolo N, Acampora A and Mirglia N. Biological monitoring of nurses exposed to doxorubicin and epirubicin by a validated liquid chromatography/fluorescence detection method. Ann Occup Hyg. 2010; 54:368-376.

Polovich M, Whitford JM and Olsen M (eds.) 2009. Chemotherapy and biotherapy guidelines and recommendations for practice (3rd. ed.) Pittsburgh, PA: Oncology Nursing Society.

Polovich M, Bolton DL, Eisenberg S, Glynn-Tucker EM, Howard-Ruben J, McDiarmid MA, Power LA and Smith CA. Safe handling of hazardous drugs. Oncol Nurs Society. Second Edition. February, 2011.

Polovich M and Giesker KE. Occupational hazardous drug exposure among non-oncology nurses. Medsurg Nurs. 2011; 20:79-85,97.

Power LA and Polovich M. Safe handling of hazardous drugs: Reviewing standards for worker protection. Pharm Practice News. June 2009: 1-8.

Polovich M and Martin S. Nurses' use of hazardous drug-handling precautions and awareness of national safety guidelines. Oncol Nurs Forum. 2011; 38:718-726.

Power LA and Polovich M. Safe handling of hazardous drugs: reviewing standards for worker protection. Pharm Practice News. March 2010; 1-8.

Power LA and Polovich M. Safe handling of hazardous drugs: reviewing standards for worker protection. Pharm Practice News. March 2011; 1-12.

Power LA and Polovich M. Safe handling of hazardous drugs: reviewing standards for worker protection. Pharm Practice News. March 2012; 1-12.

Pretty JR, Connor TH, Spasojevic I, Kurtz KS, McLaurin JL, B' Hymer C, Debord DG. Sampling and mass spectrometric analytical methods for five antineoplastic drugs in the healthcare environment. J Oncol Pharm Practice. 2010; 18:23-36.

Rombaldi F, Cassini C, Salvador M, Saffi J and Erdtmann B. Occupational risk assessment of genotoxicyty and oxidative stress in workers handeling anti-neoplastic drugs during a work week. Mutagenesis. 2009; 24:143-148.

Schierl R, Bohlandt A and Nowak D. Guidance values for surface monitoring of antineoplastic drugs in German pharmacies. Ann Occup Hyg. 2009; 53:1-9.

Schierl R, Herwig A, Pfaller A, Groebmair and Fischer E. Surface contamination of antineoplastic drug vials: Comparison of unprotected and protected vials. Am J Health-Syst Pharm. 2010; 67:428-429.

Schierl R, Novotna J, Piso P, Bohlandt A and Nowak D. Low surface contamination by cis/oxaliplatin during hyperthermic intraperitoneal chemotherapy (HIPEC). Eur J Surg Oncol. 2012; 38:88-94.

Sessink PJM, Connor TH, Jorgenson JA and Tyler TG. Reduction in surface contamination with antineoplastic drugs in 22 hospital pharmacies in the US following implementation of a closed-system drug transfer device. J Oncol Pharm Practice. 2011; 17:39-48.

Sessink PJM. Environmental contamination with cytostatic drugs: past, present, future. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu

Si P and Chan A. Common toxicities of oral anticancer agents: an overview. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu.

Siderov J, Kirsa S and McLauchlan R. Surface contamination of cytotoxic chemotherapy preparation areas in Australian hospital pharmacy departments. J Pharm Pract Res. 2009; 39: 117-121.

Siderov J, Kirsa S and McLauchlan R. Reducing workplace cytotoxic surface contamination using a closed-system drug transfer device. J Oncol Pharm Pract. 2010; 16:19-25.

Simmons CC. Oral chemotherapeutic drugs: handle with care. Nursing. 2010; 40:44-47.

Sottani C, Porro B, Cornelli M, Imbriani M and Minoia C. An analysis to study trends in occupational exposure to antineoplastic drugs among health care workers. J Chromatog B. 2010; 878:2593-2605.

Stover D and Achutan C. Occupational exposures to antineoplastic drugs in an oncology-hematology department. J Occup Environ Hyg. 2011; 8: D1-D6.

Sugiura S, Asano M, Kinoshita K, Tanimura M and Nabeshima T. Risks to health professionals from hazardous drugs in Japan: a pilot study of environmental and biological monitoring of occupational exposure to cyclophosphamide. J Oncol Pharm Practice. 2010; 17:14-19.

Suguira S, Nakanishi H, Asano M, Hashida T, Tanimura M, Hama T and Nabeshima T. Multicenter study for environmental and biological monitoring of occupational exposure to cyclophosphamide in Japan. J Oncol Pharm Practice. 2010; 17:20-28.

Sugiura S-i, Asano M, Gohma H, Nakanishi H, Hashida T and Okuda M. Obtaining insurance coverage for the use of closed systems in Japan. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu.

Suspiro A and Prista J. Biomarkers of occupational exposure do anticancer agents: a minireview. Toxicol Lett. 2011; 207:42-52.

Szmyd K and Haus O. Cancers among medical personnel exposed to anticancer agents. Med Pr. 2011; 62:17-21.

Tanimura M, Yamada K, Sugiura S, Mori K, Nagata H, Tadokoro K, Miyake T, Hamaguchi Y, Sessink P, Nabeshima T. An environmental and biological study of occupational exposure to cyclophosphamide in the pharmacy of a Japanese community hospital designated for the treatment of cancer. J Health Sci. 2009; 55: 750-756.

Touzin K, Bussières JF, Langlois É and Lefebvre M. Evaluation of surface contamination in a hospital hematology-oncology pharmacy. J Oncol Pharm Practice. 2009; 15: 53-61.

Touzin K, Bussières JF, Langlois É, Lefebvre M and Métra A. Pilot study comparing the efficacy of two cleaning techniques in reducing environmental contamination with cyclophosphamide. Ann Occup Hyg. 2010; 54:351-359.

Tuerk J, Kiffmeyer TK, Hadtstein C, Heinemann A, Hahn M, Stuetzer H, Kuss HM and Eickmann U. Development and validation of an LC-MS/MS procedure for environmental monitoring of eight cytostatic drugs in pharmacies. Intern J Environ Anal Chem. 2011; 91:1178-1190.

Turci R, Minola C, Sottani C, Coghi R, Severi P, Castriotta C, Del Bianco M and Imbriani M. Occupational exposure to antineoplastic drugs in seven Italian hospitals: the effect of quality assurance ad adherence to guidelines. J Oncol Pharm Practice. 2011; 17:320-332.

Villarini M, Dominici L, Piccinini R, Fatigoni C, Ambrogi M, Curti G, Morucci P, Muzi G, Monarca S and Moretti M. Assessment of primary, oxidative and excision repaired DNA damage in hospital personnel handling antineoplastic drugs. Mutagenesis. 2011; 26:359-369.

White RE and Easty AC. Human factors: safery lessons for oncology pharmacy practice. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu.

Willemson-McBride TL and Gehan K. Safe handling of cytotoxic agents: A team approach. AORN J. 2009; 90:731-740.

Yabunaka H, Sakaguchi F, Kobayashi Y and Nakanishi H. Investigation on vaporization of solution of Endoxan^®. Jpn J Pharm Health Care Sci. 2010; 36:343-346.

Yoshida J, Tei G, Mochizuki C, Masu Y, Koda S and Kumagai S. Use of a closed system device to reduce occupational contamination and exposure to antineoplastic drugs in the hospital work environment. Ann Occup Hyg. 2009; 53:153-160.

Yoshida J, Koda S, Nishida S, Yoshida T, Miyajima K and Kumagai S. Association between occupational exposure levels of antineoplastic drugs and work environment in five hospitals in Japan. J Oncol Pharm Practice. 2010; 17:29-38.

Zoch MD, Soefje S and Rickabaugh K. Evaluation of surface contamination with cyclophosphamide following simulated hazardous drug preparation activities using two closed-system products. J Oncol Pharm Practice. 2011; 17:49-54.

Guidelines, Recommendations and Regulations for Handling Antineoplastic Agents

Since it was first recognized that occupational exposure to antineoplastic agents posed a potential health risk to workers exposed to these agents, various groups, institutions and agencies around the world have developed and published guidelines or recommendations for handling antineoplastic agents. The most often referred to guidelines in the United States are the OSHA Technical manual: Controlling Occupational Exposure to Hazardous Drugs revised in 1995 and the NIOSH Alert: Preventing Occupational Exposure to Antineoplastic and Other Hazardous Drugs, published in 2004. Others include handling guidelines by the American Society of Hospital-System Pharmacists, the Oncology Nursing Society and the International Society of Oncology Pharmacy Practitioners.

Albin K. Administering chemotherapy: Is it safe for pregnant or breast-feeding veterinary technicians? Vet Tech. Oct 2010; E1-E5.

Alessio L, Apostoli P, Draicchio F, Forni A, Lucchini R, Merler E, Palazzo S, Scarselli R and Sossai D. Prevention of risks from occupational exposures to antineoplastic drugs: Consensus document. Med Lav. 1996; 87:194-206.

American Society of Hospital Pharmacists. Technical assistance bulletin on handling cytotoxic drugs in hospitals. Am J Hosp Pharm. 1985; 42:131-137.

American Society of Hospital Pharmacists. ASHP technical assistance bulletin on handling cytotoxic and hazardous drugs. Am J Hosp Pharm. 1990; 47:1033-1049.

American Society of Health-System Pharmacists. ASHP Guidelines on Handling Hazardous Drugs: Am J of Health-Syst Pharm. 2006; 63:1172-1193.

Association partitaire pour la santé et la sécurité du travail du secteur affaires sociaux (ASSTSAS) Prevention Guide. Safe Handling of Hazardoud Drugs. 2008.

ASTM D666-01 “Standard Practice for Field Collection of Organic Compounds from Surface Using Wipe Sampling,” ASTM International.

Barry LK and Booher RB. Promoting the responsible handling of antineoplastic agents in the community. Oncol Nurs Forum. 1985; 12:41-46.

Bonnabry P, Cingria L, Ackermann M, Sadeghipour F, Bilger L and Mach N. Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. Int J Qual Health Care. 2006; 18:9-16.

Brown KA, Esper P, Kelleher LO, O’Neill JEB, Polovich M and White JM (eds.) 2001. Chemotherapy and biotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Society.

Buchanan EC and Schneider PJ. Compounding Sterile Preparations 3rd Ed., 2009.

Canadian Society of Hospital Pharmacists. Guidlines for handling of hazardous pharmaceuticals. Can J Hosp Pharm. 1981; 34:126-128.

Canadian Society of Hospital Pharmacists, Guidelines for the handling and disposal of hazardous pharmaceuticals (Including cytotoxic drugs), Ottawa, 1993.

Canadian Occupational Health and Safety Division. Cytotoxic Drugs. Canada. 1999.

Cass Y and Musgrave CF. Guidelines for the safe handling of excreta contaminated by cytotoxic drugs. Am J Hosp Pharm. 1992; 49:1957-1958.

Cass Y. Reducing chemotherapy associated risks. Clin Pharm Eur. Sept-Dec, 2005: 1-2.

Clinical Oncology Society of Australia. Guidelines for safe handling of antineoplastic agents. Med J Australia. 1983; 1:426-428.

Colls BM. Cytotoxic chemotherapy: A potential hazard to patients and hospital personnel? The New Zealand Med J. 1987; 100:149-150.

Connor TH and MacKenzie BM. Should monoclonal antibodies and their conjugates be considered occupational hazards. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu.

Coyle B and Polovich M. Handling hazardous drugs: How safe are you? Am J Nurs. 2004; 104:104.

Council on Scientific Affairs. Guidelines for handling parenteral antineoplastics. JAMA. 1985; 253:1590-1592.

Davis MR. Handling and preparation of cytotoxic drugs-Minimizing the risk. Aust J Hosp Pharm. 1980; 10:127-30.

Davis MR. Guidelines for Safe handling of cytotoxic drugs in pharmacy departments and hosptal wards. Hosp Pharm. 1981; 16:17-20.

Davis J, McLauchlan R, Kirsa, S, Jackson J, Morey K, Ng L, Passuello F, Siderov J and Tonietto A. SHPA Standards of practice for the safe handling of cytotoxic drugs in pharmacy departments. Aust J Hosp Pharm. 1999; 29:108-116.

Deffenbaugh JH. Risks of using technicians and not pharmacists to handle antineoplastic drugs. Am J Health-Syst Pharm. 2000; 57:1750-1753.

Del Gaudio D and Menonna-Quinn D. Chemotherapy. Potential occupational hazards. Amer J Nurs, 1998; 98:59-65.

DesRoches P. Cytotoxic drug handling-Monitoring in the occupational health setting. AAOHN J. 2003; 51:106-108.

Eisenberg, S. Safe handling and administration of antineoplastic chemotherapy. J Infus Nurs. 2009; 32:23-32.

Fishman M and Mrozek-Orlowski M. Cancer chemotherapy guidelines and recommendations for practice (2nd ed.) 1999, Oncology Nursing Press, Pittsburgh.

Fortenbaugh C and Rummel M. Chemotherapy safety. Clin J Oncol Nurs. 2004; 8:424-425.

Georgiad A, Ramme E, Wretman C and Eksborg S. How to create acceptable working conditions for hospital pharmacy staff when preparing cytotoxic drugs. Euro J Hosp Pharm. 2004;3: 40-42.

Gibbs J. Handling cytotoxic drugs. Nurs Times. 1991; 87:54-55.

González-Bayó, L, González-Moreno S and Ortega-Pérez G. Safety considerations for operating room personnel during hyperthermic intraoperative intraperitoneal chemotherapy perfusion. Eur J Surg Oncol. 2006; 32:619-624.

Grajny AE, Christie D, Tichy AM and Talashek ML. Chemotherapy: How safe the caregiver? Home Healthcare Nurse. 1993; 11:51-58.

Green E, Johnston M, Trudeau M, Schwartz L, Poirier S, Macartney G and Milliken D. Safe handling of parenteral cytotoxics: Recommendations for Ontario. J Oncol Practice. 2009; 5:1-5.

Griffin E. Safety considerations and safe handling of oral chemotherapy agents. Clin J Oncol Nurs. 2003; S7:25-29.

Gullo SM. Safe handling of antineoplastic drugs: Translating the recommendations into practice. Oncol Nurs Forum. 1988; 15:595-601.

Gurwell A. Protect yourself from the hazards of anticancer drugs. RN. 1983; 46:66-67.

Harrison BR. Developing guidelines for working with antineoplastic drugs. Am J Hosp Pharm. 1981; 38:1686-1693.

Hoppe-Tichy T. Current challenges in European oncology pharmacy practice. J Oncol Pharm Pract. 2010; 16:9-18.

Italian Society of Preventive Medicine for Health Care Workers. Summary of recommendations for a rational implementation of the ministery of heath guidlines on the prevention of occupational risks in handling antineoplastic agents. Med Lav. 2001; 92:137-148. (English abstract)

International Society of Oncology Pharmacy Practitioners. Standards of Practice: Safe Handling of Cytotoxics. J Oncol Pharm Practice. 2007; 13:1-81.

Jorgenson JA, Spivey SM, Au C, Canann D, Ritter H and Smith B. Contamination comparison of transfer devices intended for handling hazardous drugs. Hosp Pharm. 2008; 43:723-727.

Jones RB, Frank R and Mass T. Safe handling of chemotherapeutic agents: A report from the Mount Sinai Medical Center. Ca-A Cancer Journal for Clinicians. American Cancer Society. 1983; 33:257-263.

Klancher JW, Vorndran M and Weiss W. Hazardous drugs: Controlling the risks in healthcare facilities. Professional Safety. Nov 2008: 24-29.

Knowles RS and Virden JE. Handling of injectable antineoplastic agents. Br J Med. 1980; 281:589-591.

Ladik CF, Stoehr GP and Maurer MA. Precautionary measures in the preparation of antineoplastics. Am J Hosp Pharm. 1980; 37:1184-1185.

Leone M, McDiarmid M, Polovich M, Coyle B, Power L, Connor TH and Reed LD. Medical surveillance for health care workers exposed to hazardous drugs. DHHS (NIOSH) Publication No. 2007-117.

LeRoy ML, Roberts MJ and Theisen JA. Procedures for handling antineoplastic injections in comprehensive cancer centers. Am J Hosp Pharm. 1983; 40:601-603.

Macek C. Hospital personnel who handle anticancer drugs may face risks. JAMA. 1982; 247:11-12.

Mahmoud S, Leonard D and Jacklin A. Cytotoxics preparation: reduction of medication errors and enhancing capacity. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu.

Massoomi F, Neff B, Rick A and Denekas P. Implementation of a safety program for handling hzardous drugs in a community hospital. Am J Heath-Sys Pharm. 2008; 65:861-865.

Mayer DK. Hazards of chemotherapy: Implementing safe handling practices. Cancer Suppl. 1992; 70:988-992.

McAllister JC and Davis SM. State regulations for home i.v. therapy. Am J Hosp Pharm. 1989; 46:1545-1546.

McDiarmid MA. Pharmaceuticals as hospital hazards: managing the risks. J Occup Med. 1991; 33:155-158.

McDiarmid MA. Public health policy activity on the safe handling of hazardous anti-cancer drugs in the healthecare workplace. Eur J Oncol. 2004; 9:81-86.

McDiarmid MA, Condon M. Organizational safety culture/climate and worker compliance with hazardous drug guidelines: lessons from the blood-borne pathogen experience. J Occup Environ Med. 2005; 47:740-749.

McLauchlan R. Safe dispensing of oral chemotherapy. Saf Considerations Oncol Pharm (Special edition, Fall 2011) www.ppme.eu.

Mellinger E, Skinker L, Sears D, Gardner D and Shult P. Safe handling of chemotherapy in the perioperative setting. AORN J. 2010; 91:435-453.

Moody DG. Veterans Administration medical center policies and procedures for handling infectable antineoplastic drugs. 1984; 41:916-919.

Moore TD, Hale KM, Cortese LM, Fillmore AD, Jozefczy KF, Scala SM and Wellman GS. Managing employee apprehension toward handling cytotoxic drugs. Am J Hosp Pharm. 1985; 42:826-831.

Murphy CP, Goldspiel BR and Koeller J. Cost of implementing Veterans Administration directives for handling antineoplastic agents. Am J Hosp Pharm. 1987; 44:788-791.

Myers CE. Pharmacy implications of the revised OSHA Hazard Communication Standard. Am J Hosp Pharm. 1989; 46:990-991.

National Study Commission on Cytotoxic Exposure. Recommendations for handling cytotoxic agents. Sept, 1987.

National Institutes of Health Publication. Recommendations for the Safe Handling of Cytotoxic Drugs. US DHHS PHS, NIH Pub No. 92-2621.

NIOSH Alert: Preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings
DHHS (NIOSH) Pub No. 2004-165, September 2004.

NIOSH: Workplace Solutions: Medical Surveillance for Health Care Workers Exposed to Hazardous Drugs. DHHS (NIOSH) Publication No. 2007-117 (2007).

NIOSH: Workplace Solutions: Personal Protective Equipment for Health Care Workers Who Work with Hazardous Drugs. DHHS (NIOSH) Publication No. 2009-106 (2008).

NIOSH: Workplace Solutions: Safe Handling of Hazardous Drugs for Veterinary Healthcare Workers. DHHS (NIOSH) Publication No. 2010-150 (June 2010).

Nixon S and Schulmeister L. Safe handling of hazardous drugs: Are you protected? Clin J Onc Nurs. 2009; 13:433-439.

Nygren O. Cytotoxic drugs. Hasselhorn HM, Toomingas A, Lagerström M (Hrsg.): Occupational Health for Health Care Workers - a Practical Guide; Page 115-120. Amsterdam, Lausanne, New York: Elsevier, 1999.

Official Journal of the European Communities. Council directive of 28 June. 1990 on the protection of workers from the risks related to exposure to carcinogens at work (90/394/EEC). No. L. 196/1-7. 26.7.90.

Oncology Nursing Society. Cancer chemotherapy guidelines and recommendations for practice. Powel, LL, ed. ONS, 1996.

Oncology Nursing Society. Standards for Cancer Nursing Practice. 1982.

OSHA Instruction TED 1.15. Directorate of technical support. Controlling occupational exposure to hazardous drugs. Sept, 1995.

OSHA [1999]. OSHA technical manual, TED 1-0.15A, Sec VI, Chapt II: Categorization of drugs as hazardous. Date accessed: January 20.

Parillo, VL. Documentation forms for monitoring occupational surveillance of healthcare workers who handle cytotoxic drugs. Oncol Nurs Forum, 1994; 21:115-120.

Peak VJ, McDaniel PA and Waite WW. Technician training module for an outpatient antineoplastic admixture program. Am J Hosp Pharm. 1987; 44:354-355.

Placentino RA, Cesarini L, Sacco A and Magnavita N. Application of the A.S.I.A. model to activities of manipulation of antineoplastic drugs. G Ital Med Lav Erg. 2003; 25S:178-179.

Polovich M. Safe handling of hazardous drugs. Online Journal of Issues in Nursing. 2004; 9 (3)Manuscript 5.

Polovich M, White J M and Kelleher LO (eds.) 2005. Chemotherapy and biotherapy guidelines and recommendations for practice (2nd. ed.) Pittsburgh, PA: Oncology Nursing Society.

Polovich M, Whitford JM and Olsen M (eds.) 2009. Chemotherapy and biotherapy guidelines and recommendations for practice (3rd. ed.) Pittsburgh, PA: Oncology Nursing Society.

Polovich M, Bolton DL, Eisenberg S, Glynn-Tucker EM, Howard-Ruben J, McDiarmid MA, Power LA and Smith CA. Safe handling of hazardous drugs. Oncol Nurs Society. Second Edition. February, 2011.

Power LA, Anderson RW, Cortopasssi R, Gera JR and Lewis RM. Update on safe handling of hazardous drugs: The advice of experts. Am J Hosp Pharm. 1990; 47:1050-1060.

Power LA and Polovich M. Safe handling of hazardous drugs: Reviewing standards for worker protection. Pharm Practice News. June 2009: 1-8.

Power LA and Polovich M. Safe handling of hazardous drugs: reviewing standards for worker protection. Pharm Pract News. March 2010; 1-8.

Power LA and Polovich M. Safe handling of hazardous drugs: reviewing standards for worker protection. Pharm Practice News. March 2011; 1-12.

Power LA and Polovich M. Safe handling of hazardous drugs: reviewing standards for worker protection. Pharm Practice News. March 2012; 1-12.

Reich SD. Antineoplastic agents as potential carcinogens: Are nurses and pharmacists at risk? Cancer Nurs. 1981; 7:500-502.

Roberts S and Sewell G. Safe handling of cytotoxics. Hosp Pharm Eur. July/August 2007: 17-19.

Schierl R, Bohlandt A and Nowak D. Gudiance values for surface monitoring of antineoplastic drugs in German pharmacies. Ann Occup Hyg. 2009; 1-9.

Scott SA, Schrott DB and Loesch GA. Pharmacy program for improved handling of antineoplastic agents. Am J Hosp Pharm. 1983; 40:1179-1182.

Scott SA. Antineoplastic drug information and handling guidelines for office-based physicians. Am J Hosp Pharm. 1984; 41:2402-2403.

Sessink PJM. Environmental contamination with cytostatic drugs: past, present, future. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu.

Si P and Chan A. Common toxicities of oral anticancer agents: an overview. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu.

Siderov J, Kirsa S and McLauchlan R. Surface contamination of cytotoxic chemotherapy preparation areas in Australian hospital pharmacy departments. J Pharm Pract Res. 2009; 39: 117-121.

Simmons CC. Oral chemotherapeutic drugs: handle with care. Nursing. 2010; 40:44-47.

Skov T, Lynge E, Maarup B, Olsen J, Rorth M and Winthereik H. Risks for physicians handling antineoplastic drugs. Lancet. 1990; 336:1446.

Skov T, Olsen J, Rorth M, Maarup B, Winthereik H and Lynge E. Cytostatics--work environment. Reassuring studies--but need for more. Sygeplejersken. 1991; 91:4-7.

Skov T. Handling antineoplastic drugs in the European Community countries. Eur J Cancer Prev. 1993; 2:43-46.

Slimowitz R and Mitrik LJ. Studies on long-term, not short-term, effects of antineoplastic drug handling are needed. Am J Hosp Pharm. 1993; 50:1862-1863.

Solimando DA. Preparation of antineoplastic drugs: A review. Am J Intraven Ther Clin Nut. 1983; September: 16-27.

Stevens KR. Safe handling of cytotoxic drugs in home chemotherapy. Sem Oncol Nurs. 1989; 5:15-20.

Stolar MH, Power LA and Viele CS. Recommendations for handling cytotoxic drugs in hospitals. Am J Hosp Pharm. 1983; 40:1163-1171.

Takada S. Principles of chemotherapy safety procedures. Clin Tech Small Anim Pract. 2003; 18:73-74.

Theiss JC. Hospital personnel who handle anticancer drugs may face risks. JAMA. 1982; 247:11-12.

U.S. Department of Labor. 1986. Guidelines for cytotoxic (antineoplastic) drugs. OSHA, Office of Occupational Medicine. Pub 8-1.1, January 1986.

U.S. Pharmacopeia (USP) Revised Chapter (797) Pharmaceutical Compounding-Sterile Preparations.

USP <797>: guidebook to pharmaceutical compounding: sterile preparations. 2008. Rockville, Md: United States Pharmacopeia.

Wagner JT, Considerations for Choosing a Primary engeneering control for compounding sterile products. Int J Pharm Comp. 2005; 9:284-290.

Widströ m J and Edling C. Antineoplastic Agents. In DK Brune and Edling C (Eds.) Occupational Hazards in Health Professions. 1989. Boca Raton, FL: CRC Press, Inc.

White RE and Easty AC. Human factors: safery lessons for oncology pharmacy practice. Saf Considerations Oncol Pharm (Special edition) Fall 2011) www.ppme.eu.

White SK, Stephens AD, Dowjat B and Sugarbaker PH. Safety constiderations [sic] in the use of interoperative intraperitoneal chemotherapy. Cancer Treatment and Research, PH Sugarbaker (ed.) Kluwer Academic Publichers, Boston, 1996; 311-316.

Willemson-McBride TL and Gehan K. Safe handling of cytotoxic agents: A team approach. AORN J. 2009; 90:731-740.

Williamson KM, Turner JG, Brown KC, Newman KD, Sirles AT and Selleck CS. Occupational health hazards for nurses--Part II. Image: J Nurs Schol. 1988; 20:162-168.

Young RL and DuVall EM. Chemotherapy exposure file. Am J Hosp Pharm. 1985; 42:1990-1991.

Zellmer WA. Fear of anticancer drugs. Am J of Hosp Pharm. 1984; 42:665.

Zimmerman PF, Laresen RK, Barkley EW and Gallelli JF. Recommendations for the safe handling of injectable antineoplastic drug products. Amer Journal Hosp Pharm. 1981; 38:1693-1695.

Review Articles

Several authors have published articles reviewing the topic of occupational exposure to antineoplastic agents. These articles provide a good starting place for individuals not familiar with this area to learn more of what some of the issues are and what type of studies have been performed in this area.

Baker ES and Connor TH. Monitoring occupational exposure to cancer chemotherapy drugs. Am J Health-Syst Pharm. 1996; 53:2713-2723.

Bos RP and Sessink PJM. Biomonitoring of occupational exposure to cytostatic anticancer drugs. Rev Environ Health. 1997; 12:43-58.

Bussières JF, Touzin K and Lefebvre M. Monitoring of hazardous drugs in hospital practice. Hosp Pharm Eur. 2007; July/August: 21-24.

Cass Y. Hospital pharmacy in Israel. Hosp Pharm Eur. 2005; Sept/Oct:86-87.

Cass Y. Reducing chemotherapy-associated risks. Clin Pharm Eur. 2006; Sept-Dec :1-2.

Cass Y and Setton I. 25 years of safe handling of cytotoxics (antineoplastics) in Israel. J Oncol Pharm Practice. 2006; 12:83-90.

Connor TH. Hazardous anticancer drugs in health care: Environmental Exposure Assessment. Ann NY Acad Sci. 2006; 1076:615-623.

Connor TH and McDiarmid MA. Preventing occupational exposures to antineoplastic drugs in health care settings. CA Cancer J Clin. 2006; 56:354-365.

Davis J, McLauchlan R and Connor TH. Exposure to hazardous drugs in healthcare: an issue that will not go away. J Oncol Pharm Practice. 2011; 17:9-13.

Del Gaudio D and Menonna-Quinn D. Chemotherapy: Potential Occupational Hazards. AJN. 1998; 98: 59-65.

DesRoches P. Cytotoxic drug handling-Monitoring in the occupational health setting. AAOHN J. 2003; 51:106-108.

Forni A, Bonatti S and Merler E. Cytogenetic indicators of genotoxicity in subjects occupationally exposed to antineoplastic drugs. Med Lav. 1996; 87:222-229. [English abstract]

Fransman W, Occupational exposure to cytotoxic drugs. Hospital Pharmacy Eur. 2007; 35:85-86.

Fransman W, Peelen S, Hilhorst S, Roeleveld N, Heederik D and Kromhout H. A pooled analysis to study trends in exposure to antineoplastic drugs among nurses. Ann Occup Hyg. 2007; 51:231-239.

Furlow B. How to improve the safety of chemotherapy administration. Oncol Nurse Advisor. 2010; 21-25.

Halsen G and Kramer I. Assessing the risk to health care staff from long-term exposure to anticancer drugs - the case of monoclonal antibodies. J Oncol Pharm Practice. 2011; 17:68-80.

McDiarmid MA. Medical surveillance for antineoplastic-drug handlers. Am J Hosp Pharm. 1990; 47: 1061-1066.

McDiarmid MA, Gurley HT and Arrington D. Pharmaceuticals as hospital hazards: Managing the risks. JOEM. 1991; 33: 155-158.

Nussbaumer S, Bonnabry P, Veuthey JL and Fleury-Souverain S. Analysis of anticancer drugs: a review. Talanta. 2011; 85:2265-2289.

Piekarczyk A, Grzesiuk E, Zimak J and Taljanski W. Are cytostatic drugs and their metabolites, excreted by patients during chemotherapy, hazardous for the family environment? Medycyna Wieku Rozwojowego. 2001; V Suplemtnt I do nr 3.(English abstract)

Polovich M. Safe handling of hazardous drugs. Online Journal of Issues in Nursing. 2004; 9 (3)Manuscript 5.

Polovich M and Giesker KE. Occupational hazardous drug exposure among non-oncology nurses. Medsurg Nurs. 2011; 20:79-85, 97.

Power LA. Hazardous drugs in oncology: the impact on practices of USP <797> and the NIOSH alert. Community Oncol. 2008; 5:343-346.

Rogers B. Investigations of work-related exposures to antineoplastic agents: An overview of the literature. Sem Occup Med. 1987; 2:83-89.

Roller M, Eickmann U and Nies E. Krebsrisiko durch beruflichen Umgang mit Zytostatika- quantitative Betrachtungen. Hauptverband der gewerblichen Berufsgenossenschaften; BIA-Report 5/2001.(English Abstract)

Sessink PJM and Bos RP. Drugs hazardous to healthcare workers:Evaluation of methods for monitoring occupational exposure to cytotoxic drugs. Drug Safety. 1999; Apr 20 (4): 347-359.

Sorsa M, Hemminki K and Vainio H. Biologic monitoring of exposure to chemical mutagens in the occupational environment. Teratogenesis Carcinog Mutagen. 1982; 2:137-150.

Sorsa M, Hemminki K and Vainio H. Occupational exposure to anticancer drugs-Potential and real hazards. Mutat Res. 1985; 154:135-149.

Sorsa M and Anderson D. Monitoring of occupational exposure to cytostatic anticancer agents. Mutat Res. 1996; 355:253-261.

Sorsa M, Hamelia M and Jarviluoma E. Handling anticancer drugs: from hazard identification to risk management? Ann NY Acad Sci. 2006; 1076:628-634.

Stellman JM and Zoloth SR. Cancer chemotherapeutic agents as occupational hazards: A literature review. Cancer Invest. 1986; 4:127-135.

Suspiro A and Prista J. Biomarkers of occupational exposure do anticancer agents: a minireview. Toxicol Lett. 2011; 207:42-52.

Tilyou S. Cytotoxic drug residues still lurking in health care facilities: 75% of wipe samples from several hospitals deemed contaminated with at least one chemotherapeutic agent. HEM/ONC Pharm in Focus. 2010; 37 (01).

Trossman S. Hazardous conditions. Am J Nurs. 2006; 106:75-78.

Turci R, Sottani C, Spagnoli G and Minoia C. Biological and environmental monitoring of hospital personnel exposed to antineoplastic agent: a review of analytical methods. J Chromatog B. 2003; 789:169-209.

Vanchieri C. Health hazard to community practice nurses: the 'big worry'. Community Oncol. 2005; 2:277-279.

Vandenbroucke J. Quality assurance project in a university hospital-2 years of experience. EHP. 2001; 7: 60-68.

Vaughn MC and Christensen WD. Occupational exposure to cancer chemotherapeutic drugs: A literature review. Am Ind Hyg Assoc J. 1985; 46:B8-B18.

Surveys

A number of surveys have examined work practice standards and compliance with guidelines for the proper handling of antineoplastic agents.

Ben-Ami S, Shaham J, Rabin S, Melzer A and Ribak J. The influence of nurses' knowledge, attitudes, and health beliefs on their safe behavior with cytotoxic drugs in Israel. Cancer Nurs. 2001; 24:192-200.

Cohen IA, Newland SJ and Kirking DM. Injectable-antineoplastic-drug practices in Michigan hospitals. Am J Hosp Pharm. 1987; 44:1096-1105.

Friese CR, Himes-Ferris L, Fraier MN, McCullagh MC and Griggs JJ. Structures and processes of care in ambulatory oncology settings and nurse-reported exposure to chemotherapy. BMJ Qual Saf. 2011; August 16 (Epub ahead of printing) doi:10.1136/bmjqs-2011-000178.

Fuller TP, Bain EI and Sperrazza K. A survey of the status of hazardous drug awareness and control in a sample Massachusetts nursing population. J Occup Environ Hyg. 2007; 4:D113-119.

Gambrell J and Moore S. Assessing workplace compliance with handling of antineoplastic agents. Clin J Onc Nurs. 2006; 10:473-477.

Gilbar PJ. External contamination of cytotoxic drug vials. J Pharm Pract Res. 2005; 35:264-265.

Gregoire RE, Segal R and Hale KM. Handling antineoplastic-drug admixtures at cancer centers: Practices and pharmacist attitudes. Am J Hosp Pharm. 1987; 44:1090-1095.

Kyprianou M, Kapsou M, Raftopoulos V and Soteriades ES. Knowledge, attitudes and beliefs of Cypriot nurses on the handling of antineoplastic agents. Eur J Oncol Nurs. 2010; 14:278-282.

Mahon SM, Casperson DS, Yackzan S, Goodner S, Hasse B, Hawkins J, Parham J, Rimkus C, Schlomer M and Witcher V. Safe handling practices of cytotoxic drugs: The results of a chapter survey. Oncol Nurs Forum. 1994; 21:1157-1165.

Martin S. Chemotherapy-handling practices of outpatient and office-based oncology nurses. Onc Nurs Forum. 2003; 30:575-581.

Nieweg RMB, de Boer M, Dubbleman RC, Gall HE, Hesselman GM, Lenssen PCHP, van Maanen LWGM, Majoor PWFM and Slegt JH. Safe handling of antineoplastic drugs. Cancer Nurs. 1994; 17:501-511.

Polovich M and Martin S. Nurses' use of hazardous drug-handling precautions and awareness of national safety guidelines. Oncol Nurs Forum. 2011; 38:718-726.

Sauer KA, Coons SJ and Berger PK. Survey of training, handling practices, and risk perceptions of Kentucky pharmacists working with antineoplastic agents. Am J Hosp Pharm. 1991; 48:119-120.

Stellman JM, Aufiero BM and Taub RN. Assessment of potential exposure to antineoplastic agents in the health care setting. Prev Med. 1984; 13:245-255.

Turk M, Davas A, Ciceklioglu M, Sacaklioglu F and Mercan T. Knowledge, attitude and safe behaviour of nurses handling cytotoxic anticancer drugs in Ege University Hospital. Asian Pac J Cancer Prev. 2004; 5:164-168.

Valanis B and Shortridge L. Self protective practices of nurses handling antineoplastic drugs. Oncol Nurs Forum. 1987; 14:23-27.

Valanis B, McNeil V and Driscoll K. Staff members' compliance with their facility's antineoplastic drug handling policy. Oncol Nurs Forum. 1991; 18:571-576.

Valanis B, Vollmer WM, Labuhn K, Glass A and Corelle C. Antineoplastic drug handling protection after OSHA guidelines: Comparison by profession, handling activity and work site. J Occup Med. 1992; 34:149-155.

Yoshida J, Kosaka H, Nishida S and Kumagai S. Actual conditions of the mixing of antineoplastic drugs for injection in hospitals in Osaka Prefecture, Japan. J Occup Health. 2008; 50:86-91.