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HAZARDOUS DRUG EXPOSURES IN HEALTHCARE

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Recent Publications, Guidelines, Review Articles and Surveys

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

  • AIHA Healthcare Working Group Hazardous Drugs Project Team. Chemotherapy hood decommissioning for disposal or recycling. Fact sheet. Approved by AIHA Board: October 17, 2016. Falls Church, VA: American Industrial Hygiene Association (AIHA).
  • Alehashem M and Baniasadi S. Important exposure controls for protection against antineoplastic agents: highlights for oncology health care workers. Work 2018; 59:165-172.
  • Alexander K, Northrup N, Clarke D, Lindell H and Laver T. Engineering controls in veterinary oncology: a survey of 148 ACVIM board-certified oncologists and environmental surveillance in 20 specialty hospitals. Vet Comp Oncol 2018; 16:385-391.
  • Alexander M, King J, Lingaratnam S, Byrne J, MacMillan K, Mollo A, Kirsa S and Green M. A survey of manufacturing and handling practices for monoclonal antibodies by pharmacy, nursing and medical personnel. J Oncol Pharm Pract. 2016; 22(2):219-227.
  • Ametsbichler P, Böhlandt A, Nowak D and Schierl R. Occupational exposure to cisplatin/oxaliplatin during Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC)? Eur J Surg Oncol 2018; 44:1793-1799.
  • Bach PB, Conti RM, Muller RJ, Schnorr GC and Saltz LB. Overspending driven by oversized single dose vials of cancer drugs. BMJ. 2016; 352:i788.
  • Barle EL, Winkler GC, Glowienke S, Elhajouji A, Nunic J and Martus HJ. Setting occupational exposure limits for genotoxic substance in the pharmaceutical industry. Toxicol Sci. 2016; 151:2-9.
  • Bartel SB, Tyler TG and Power LA. Multicenter evaluation of a new closed system drug-transfer device in reducing surface contamination by antineoplastic hazardous drugs. Am J Health Syst Pharm 2018; 75:199-211.
  • Bayraktar-Ekincioglu A, Korubük G and Demirkan K.  An evaluation of chemotherapy drug preparation process in hospitals in Turkey: a pilot study. J Oncol Pharm Pract 2018; 24:563-573.
  • Breukels O, van der Gronde T, Simons-Sanders K and Crul M. Antineoplastic drug contamination on the outside of prepared infusion bags. IJPC Intern J Pharmaceutical Compounding 2018; 22:345-349.
  • Canal-Raffin M, Khennoufa K, Martinez B, Goujon Y, Folch C, Ducint D, Titier K, Brochard P, Verdun-Esquer C, Molimard M. Highly sensitive LC-MS/MS methods for urinary biological monitoring of occupational exposure to cyclophosphamide, ifosfamide, and methotrexate antineoplastic drugs and routine application. J Chromatogr B. 2016; 1038:109–117.
  • Cass Y, Connor TH, Tabachnik A [2017]. Safe handling of oral antineoplastic medications: focus on targeted therapeutics in the home setting. J Oncol Pharm Pract 2017 Jul; 23(5):350-378external icon.
  • Celano P, Fausel CA, Kennedy EB, Miller TM, Oliver TK, Page R, Ward JC and Zon RT. Safe handling of hazardous drugs: ASCO standards. J Clin Oncol 2019; DOI: 10.1200/JCO.18.01616.
  • Chen H-C, Lu Z-YJ and Lee S-H. Nurses’ experiences in safe handling of chemotherapeutic agents: the Taiwan case. Cancer Nursing. 2016; 39:e29–38.
  • Connor TH, Douglass K, Eisenberg S, Kastango ES, Kienle PC, Massoomi F and Parsad SD. Improving safe handling practices for hazardous drugs: toolkit. Mansur J, contributing editor. 2016. Joint Commission Resources (www.jcrinc.comexternal icon).
  • Connor TH, Celano P, Frame JN and Zan RT. Summary of the Workshop on the Safe Handling of Hazardous Drugs Cohosted by the National Institute for Occupational Safety and Health and the American Society of Clinical Oncology. J Oncol Pract 2017; 13:199-205.
  • Connor TH, Smith JP [2016]. New approaches to wipe sampling methods for antineoplastic and other hazardous drugs in healthcare settings. Pharm Technol Hosp Pharm 2016 Sep; 1(3):107-114external icon.
  • Connor TH, Zock MD, Snow AH [2016]. Surface wipe sampling for antineoplastic (chemotherapy) and other hazardous drug residue in healthcare settings: methodology and recommendations. J Occup Environ Hyg 2016 Sep; 13(9):658-667external icon.
  • Cox J, Speed V, O’Neal S, Hasselwander T, Sherwood C, Eckel SF and Zamboni WC. Development and evaluation of a novel product to remove surface contamination of hazardous drugs. J Oncol Pharm Pract. 2017; 23:103-115.
  • Crul M and Simons-Sanders K. Carry over of antineoplastic drug contamination in Dutch hospital pharmacies. J Oncol Pharm Pract 2018; 24:483-489.
  • Cytotoxic Drugs and Related Waste: A Risk Management Guide for South Australian Health Services.
  • Dal Bello F, Santoro V, Scarpino V, Martano C, Aigotti R, Chiappa A, Davoli E and Medana C. Antineoplastic drugs determination by HPLC-HRMSn to monitor occupational exposure. Drug Test Anal. 2016; 8:730-737.
  • DeJoy DM, Smith TD, Woldu H, Dyal M-A, Steege AL and Boiano JM. Effects of organizational safety practices and perceived safety climate on PPE usage, engineering controls, and adverse events involving liquid antineoplastic drugs among nurses. J Occup Environ Hyg. 2017; 14:485-493.
  • Dugheri S, Bonari A, Pompilio I, Boccalon P, Tognoni D, Cecchi M, Ughi M, Mucci N and Arcangeli G. Analytical strategies for assessing occupational exposure to antineoplastic drugs in healthcare workplaces. Medycyna Pracy 2018; 69:589-604.
  • Eisenberg S. Hazardous drugs and USP <800>: implications for nurses. Clin J Oncol Nurs. 2017; 21:179–187.
  • Eisenberg S. A call to action for hazardous drug safety: Where we have been and where we are going. Clin J Onc Nurs. 2016; 20: A1-A8.
  • Elshaer NS. Adverse health effects among nurses and clinical pharmacists handling antineoplastic drugs: adherence to exposure control methods. J Egypt Public Health Assoc 2017; 92:144-155.
  • Fabrizi G, Fioretti M and Rocca LM. Dispersive solid-phase extraction procedure coupled to UPLC-ESI-MS/MS analysis for the simultaneous determination of thirteen cytotoxic drugs in human urine. Biomed Chromatogr. 2016; 30:1297-1308.
  • Forshay CM, Streeter SO, Salch SA and Eckel SF. Application of the 2015 proposed NIOSH vapor containment performance protocol for closed system transfer devices used during pharmacy compounding and administration of hazardous drugs. J Oncol Pharm Pract 2018; July, doi: 10.1177/1078155218787256external icon.
  • Garcia SV, Clérigues NV, Ferrer VF and Briz EL. Use and handling of Mini-Spike 2® chemo and puresite for safe chemotherapy compounding in a hospital pharmacy. Reg Toxicol Pharm 2018; 100:1-6.
  • Garrigue P, Montana M, Ventre C, Gauthier-Villano L, Pisano P and Pourroy B. Safe cytotoxic drug preparation using closed-system transfer device: technical and practical evaluation of a new device (Vialshield/Texium) comparatively to a reference one (Phaseal). Int J Pharm Compounding. 2016; 20:148-154.
  • Gianfredi V, Salvatori T, Nucci D, Villarini M and Moretti M. Rischio genotossico da manipolazione di farmad chemioterapid antiblastid negli operatori sanitari professionalmente esposti: revisione sistematica della letteratura e meta-analisi. Recenti Prog Med 2017; 108:511-520. (Italian with English abstract)
  • Gomez-Alvarez S, Porta-Oltra B, Hernandez-Griso M, Perez-Labana F and Climente-Marti M. Evaluacion de dos sistemas cerrados en el proceso de elaboracion de quimioterapia parenteral. Farm Hosp. 2016; 40:36-43.
  • Graeve CU, McGovern PM, Alexander B, Church T, Ryan A and Polovich M. Occupational exposure to antineoplastic agents: an analysis of health care workers and their environments. Workplace Health and Safety. 2016 (e-pub; doi: 10.117712.165079916662660).
  • Graeve C, McGovern PM, Arnold S and Polovich M. Testing an intervention to decrease healthcare workers’ exposure to antineoplastic agents. ONF April 2017; 44(1):E10–E19.
  • Health and Safety Executive. Safe handling of cytotoxic drugs in the workplaceexternal icon.
  • He BY, Mendelsohn-Victor K, Mccullagh MC and Friese CR. Personal protective equipment use and hazardous drug spills among ambulatory oncology nurses. ONF 2017; 44: 60–65.
  • Ho KV, Edwards MS, Solimando DA Jr, Johnson AD. Determination of extended sterility for single-use vials using the Phaseal closed-system transfer device. J Hematol Oncol Pharm. 2016; 6:46-50.
  • Hon CY and Abusitta D. Causes of health care workers’ exposure to antineoplastic drugs: an exploratory study. Can J Hosp Pharm. 2016; 69:216-223.
  • Johnson TM. Long-term care: safe drug handling of oral chemotherapy. The Consultant Pharmacist. 2017; 32:74–83.
  • Kibby T. A review of surface wipe sampling compared to biologic monitoring for occupational exposure to antineoplastic drugs. J Occup Environ Hyg. 2017; 14:159–174.
  • King J, Alexander M, Byrne J, MacMillan K, Mollo A, Kirsa S and Green M. A review of the evidence for occupational exposure risks to novel anticancer agents – A focus on monoclonal antibodies. 2016;22:121-134.
  • Koller M, Böhlandt A, Haberl C, Nowak D and Schierl R. Environmental and biological monitoring on an oncology ward during a complete working week. Toxicol Letters 2018; 298:158-163.
  • Krämer I, Federici M. Kaiser V and Thiesen J. Media-fill simulation tests in manual and robotic aseptic preparation of injection solutions in syringes. J Oncol Pharm Pract. 2016; 22:195-204.
  • Kunneva L. Closed system drug transfer devices for chemotherapy. Nursing. 2016; 46:67-68.
  • Lawson CC, Johnson CY, Nassan FL, Connor TH, Boiano JM, Rocheleau CM, Chavarro JE and Rich-Edwards JW. Antineoplastic drug administration by pregnant and nonpregnant nurses: an exploration of the use of protective gloves and gowns. AJN Am J Nurs 2019; 119:28-35.
  • Le LMM, Reitter D, He S, Bonle FT, Launois A, Martinez D, Prognon P and Caudron E. Safety analysis of occupational exposure of healthcare workers to residual contaminations of cytotoxic drugs using FMECA security approach. Sci Total Environ. 599-600 (2017) 1939-1944.
  • Mathias Pl, Connor TH and B’Hymer C. A review of high performance liquid chromatographic-mass spectrometric urinary methods for anticancer drug exposure of health care workers. J Chromatography B 2017; 1060:316-324.
  • Mathias PI, MacKenzie BA, Toennis CA and Connor TH. Survey of guidelines and current practices for safe handling of antineoplastic and other hazardous drugs used in 24 countries. J Oncol Pharm Pract 2019; 25:148-162.
  • Müller-Ramírez C, Squibb K and McDiarmid M. Measuring extent of surface contamination produced by the handling of antineoplastic drugs in low-to-middle-income country oncology health care settings. Arch Occup Environ Health. 2017; 72:289-298.
  • Müller-Ramírez C, Squibb K and McDiarmid M. Accessible analytical methodology for assessing workplace contamination of antineoplastic drugs in limited-resource oncology health-care settings. J Anal Sci and Technol. 2016; 7:11.
  • Nurgat ZA , Lawrence M , Elhassan TA , Al Nahedh M , Ashour M , Alaboura D ,  Al-Jazairi AS and  Al-jedai A. Comparison of closed system transfer devices for turnaround time and ease of use. J Oncol Pharm Pract 2018. DOI: 10.1177/1078155218781900.
  • Panahi D, Azari M, Akbari ME, Zendehdel R, Mirzaei HR, Hatami H and Mehrabi Y. Development of a new method for sampling and monitoring oncology staff exposed to cyclophosphamide drug. Environ Monit Assess. 2016; 188:238-243.
  • Pérez-Minayo MF, Bazán EC, Segurado MH, Moya MAA, Torres PP and Martinez FJB. Use of closed systems in the hospital pharmacy. Farm Hosp. 2016; 40:102–17.
  • Polovich M. Minimizing occupational exposure to antineoplastic agents. J Infus Nurs. 2016; 39:307–313.
  • Poupeau C, Tanguay C, Caron NJ and Bussières J-F. Multicenter study of environmental contamination with cyclophosphamide, ifosfamide, and methotrexate in 48 Canadian hospitals. J Oncol Pharm Pract 2018; 24:9-17.
  • Poupeau C, Tanguay C, Plante C, Gagne S, Caron N and Bussieres JF. Pilot study of biological monitoring of four antineoplastic drugs among Canadian healthcare workers. J Oncol Pharm Pract. 2017; 23:323–332.
  • Power LA, Polovich M. Safe handling of hazardous drugs: reviewing standards for worker protection. Pharm Pract News 2016; Special Edition:23-36.
  • Redic KA, Fang K, Christen C and Chaffee BW. Surface contamination of hazardous drug pharmacy storage bins and pharmacy distributor shipping containers. J Oncol Pharm Pract 2018; 24:91-97.
  • Rodier S, Saint-Lorant G, Guillot J-M, Palix A, Divanon F, Sichel F and Delépée R. Is hyperthermic intraperitoneal chemotherapy (HIPEC) safe for healthcare workers? Surg Oncol. 2017; 26:242–51.
  • Roussel C, Witt KL, Shaw PB and Connor TH. Meta-analysis of chromosomal aberrations as a biomarker of exposure in healthcare workers occupationally exposed to antineoplastic drugs. Mutation Research: Reviews in Mutation Research 2017, http://dx.doi.org/10.1016/j.mrrev.2017.08.002external icon.
  • Sakhvidi MJZ, Hajaghazadeh M, Mostaghaci M, Mehrparvar AH, Sakhvidi FZ and Naghshineh E. Applicability of the comet assay in evaluation of DNA damage in healthcare providers’ working with antineoplastic drugs: a systematic review and meta-analysis. Int J Occup Environ Health. 2016; 22:52-67.
  • Schierl R, Masini C, Groeneveld S, Fischer E, Bohlandt A, Rosini V and Paolucci D. Environmental contamination by cyclophosphamide preparation: comparison of conventional manual production in biological safety cabinet and robot-assisted production by APOTECAchemo. J Oncol Pharm Pract. 2016; 22(1):37-45.
  • Sidikou O, Simon N, Sergent G, Vasseur M, Pinturaud M, Richeval C, Allorge D, Decaudin B and Odou P. In vitro assessment of a new extension set intended to reduce occupational exposure to antineoplastic drugs during hepatic chemoembolisation. Cardiovasc Intervent Radiol. 2016; 39(1):141-3.
  • Silver SR, Steege AL and Boiano JM. Predictors of adherence to safe handling practices for antineoplastic drugs: a survey of hospital nurses. J Occup Environ Hyg. 2016; 13:203-212.
  • Simon N, Vasseur M, Pinturaud M, Soichot M, Richeval C, Humbert L, Lebecque M, Sidikou O, Barthelemy C, Bonnabry P, Allorge D, Décaudin B and Odou P. Effectiveness of a closed-system transfer device in reducing surface contamination in a new antineoplastic drug compounding unit: a prospective, controlled, parallel study. PLOS ONE. 2016; 11:e0159052.
  • Smith JP, Sammons DL, Pretty JR, Kurtz KS, Robertson SA, DeBord DG, Connor TH and Snawder JE. Detection of 5-fluorouracil surface contamination in near real time. J Oncol Pharm Pract. 2016; 22:396-408.
  • Smith JP, Sammons DL, Robertson SA, Pretty JR, DeBord DG, Connor TH and Snawder JE. Detection and measurement of surface contamination by multiple antineoplastic drugs using multiplex bead assay. J Oncol Pharm Pract. 2016; 22 (1): 60-67.
  • Soltani C, Grignani E, Zaratin L, Santorelli D, Studioso E, Lonati D, Locatelli CA, Pastoris O, Negri S and Cottica D. A new, sensitive and versatile assay for quantitative determination of α-fluoro-β-alanine (AFBA) in human urine by using the reversed-phase ultrahigh performance-tandem mass spectrometry (rp-UHPLC-MS/MS) system. Toxicol Letters 2018; 298:164-170
  • Sussman RG, Schatz AR, Kimmel TA, Ader A, Naumann BD and Weideman PA. Identifying and assessing highly hazardous drugs within quality risk management programs. Regul Toxicol Pharmacol. 2016; 79:S11–18.
  • Vazquez R, Boubet K, Guerrault-Moro MN and Crauste-Manciet S. Impact of handling errors for chemical cross-contamination risk for the preparation of parenteral cytotoxic drugs. Pharm Technol Hosp Pharm. 2016;1:115-122.
  • Villarinia M, Gianfredia V, Levoratoa S, Vannini S, Salvatori T and Moretti M. Occupational exposure to cytostatic/antineoplastic drugs and cytogenetic damage measured using the lymphocyte cytokinesis-block micronucleus assay: a systematic review of the literature and meta-analysis. Mutat Res. 2016; 770(Pt A):35–45.
  • Vyas N, Turner A, Clark JM and Sewell GJ. Evaluation of a closed-system cytotoxic transfer device in a pharmaceutical isolator. J Oncol Pharm Pract. 2016; 22(1):10-19.
  • Walton AML, Eisenberg S and Friese CR. Hazardous drugs: legislative and regulatory efforts to improve safe handling. Clin J Oncol Nurs. 2017; 21:254–256.
  • Whitaker P. Occupational allergy to pharmaceutical products. Curr Opin Allergy Clin lmmunol 2016; 16:101-106.
  • Wilkinson A-S, Allwood MC, Morris CP, Wallace A, Finnis R, Kaminska, E and Hemingway, M. Performance testing protocol for closed-system transfer devices used during pharmacy compounding and administration of hazardous drugs. PLOS ONE 2018; 13:1-15.
  • Zhang J, Bao J, Wang R, Geng Z, Chen Y, Xie XY, Jiang L, Deng Y, Liu G, Xu R and Miao L. A multicenter study of biological effects assessment of pharmacy workers occupationally exposed to antineoplastic drugs in pharmacy intravenous admixture services. J Haz Mat. 2016; 315: 86–92.
  • Zhang X, Zheng Q, Lv Y, An M, Zhang Y, Wei Y and Feng W. Evaluation of adverse health risks associated with antineoplastic drug exposure in nurses at two Chinese hospitals: the effects of implementing a pharmacy intravenous admixture service. Am J Ind Med. 2016; 59:264–273.

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.

  • Ahmad N, Simanovski V, Hertz S, Klaric G, Kaizer L and Krzyzanowska MK. Oral chemotherapy practices at Ontario cancer centres. J Oncol Pharm Pract. 2015; 21(4): 249-257.
  • 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.
  • 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. Int J Occup Environ Health. 1997; 3:84-87.
  • Alexander M, King J, Bajel C, Doecke C, Fox P, Lingaratnam S, Mellor JD, Nicholson L, Roos I, Saunders T, Wilkes J, Zielinski R, Byrne J, MacMillan K, Mollo A, Kirsa S and Green M. Australian consensus guidelines for the safe handling of monoclonal antibodies for cancer treatment by healthcare personnel. Intern Med J. 2014; (Epub ahead of print) DOI: 10.111/imj.12564.
  • Alexander M, King J, Bajel A, Doecke C, Fox P, Lingaratnam S, Mellor JD, Nicholson L, Roos I, Saunders T, Wilkes J, Zielinski R, Byrne J, MacMillan K, Mollo A, Kirsa S and Green M. Australian consensus guidelines for the safe handling of monoclonal antibodies for cancer treatment by healthcare personnel. Intern Med J. 2014; 44:1018-1026.
  • 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 Health-Syst Pharm. 2006; 63:1172-1193.
  • Anon. Practice fined for health and safety record. Vet Rec. 2014; 175:418.
  • Association partitaire pour la santé et la sécurité du travail du secteur affaires sociaux (ASSTSAS) Prevention Guide. Safe Handling of Hazardous Drugs. 2008.
  • ASTM D666-01 “Standard Practice for Field Collection of Organic Compounds from Surface Using Wipe Sampling,” ASTM International.
  • Barle EL, Winkler GC, Glowienke S, Elhajouji A, Nunic J and Martus HJ. Setting occupational exposure limits for genotoxic substance in the pharmaceutical industry. Toxicol Sci. 2016; 151:2-9.
  • Barry LK and Booher RB. Promoting the responsible handling of antineoplastic agents in the community. Oncol Nurs Forum. 1985; 12:41-46.
  • Beaver CC and Magnan MA. Minimizing staff exposure to antineoplastic agents during intravesical therapy. Clin J Oncol Nurs. 2015; 19:393-395.
  • BCCA [2008]. Module 1: Safe handling of hazardous drugs. In: BC cancer agency pharmacy practice standards for hazardous drugs. www.bccancer.bc.ca/HPI/Pharmacy/GuidesManuals/safehandling.htm Date accessed: January 2013.
  • 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.
  • Celano P, Fausel CA, Kennedy EB, Miller TM, Oliver TK, Page R, Ward JC and Zon RT. Safe handling of hazardous drugs: ASCO standards. J Clin Oncol 2019; DOI: 10.1200/JCO.18.01616.
  • 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.
  • Clinical Oncology Society of Australia. Guidelines for safe handling of antineoplastic agents. Med J Australia. 1983; 1:426-428.
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  • 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.euexternal icon.
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  • Council on Scientific Affairs. Guidelines for handling parenteral antineoplastics. JAMA. 1985; 253:1590-1592.
  • Cytotoxic Drugs and Related Waste: A Risk Management Guide for South Australian Health Services
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  • Davis MR. Guidelines for Safe handling of cytotoxic drugs in pharmacy departments and hosptal wards. Hosp Pharm. 1981; 16:17-20.
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  • 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.
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  • Ferron G, Simon L, Guyon F, Glehen O, Goere D, Elias D, Pocard M, Gladieff L, Bereder JM, Brigand C, Classe JM, Guilloit JM, Quenet F, Abboud K, Arvieux C, Bibeau F, De Chaisemartin C, Delroeux D, Durand-Fontanier S, Goasguen N, Gouthi L, Heyd B, Kianmanesh R, Leblanc E, Loi V, Lorimier G, Marchal F, Mariani P, Mariette C, Meeus P, Msika S, Ortega-Deballon P, Paineau J, Pezet D, Piessen G, Pirro N, Pomel C, Porcheron J, Pourcher G, Rat P, Regimbeau JM, Sabbagh C, Thibaudeau E, Torrent JJ, Tougeron D, Tuech JJ, Zinzindohoue F, Lundberg P, Herin F and Villeneuve L. Professional risks when carrying out cytoreductive surgery for peritoneal malignancy with hyperthermic intraperitoneal chemotherapy (HIPEC): a French multicentric survey. Eur J Surg Oncol. 2015; 41:1361-1367.
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  • Gambrell J and Moore S. Assessing workplace compliance with handling of antineoplastic agents. Clin J Oncol Nurs. 2006; 10:473-477.
  • 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.
  • Goodin S. Advancing the safe and appropriate use of oral chemotherapy agents. Am J Health-Syst Pharm. 2007; 64:S1-40.
  • Goodin S, editor. Advancing the safe and appropriate use of oral chemotherapy agents. Articles based on the proceedings of an interdisciplinary educational program. Am J Health-Syst Pharm. 2007; 64(Suppl 5): S1–S36.
  • Goodin S, Griffith N, Chen B, Chuk K, Daouphars M, Doreau C, Patel RA, Schwartz R, Tames MJ, Terkola R, Vadnais B, Wright D and Meier K. Safe handling of oral chemotherapeutic agents in clinical practice: recommendations from an international pharmacy panel. J Oncol Pract. 2011; 7:7-12.
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  • 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 Pract. 2009; 5:1-5.
  • 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.
  • 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.
  • Health and Safety Executive. Safe handling of cytotoxic drugs in the workplaceexternal icon.
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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.

  • Alehashem M and Baniasadi S. Important exposure controls for protection against antineoplastic agents: highlights for oncology health care workers. Work 2018; 59:165-172.
  • Bach PB, Conti RM, Muller RJ, Schnorr GC and Saltz LB. Overspending driven by oversized single dose vials of cancer drugs. BMJ. 2016; 352:i788.
  • 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, Connor TH and Tabachnik A. Safe handling of oral antineoplastic medications: focus on targeted therapeutics in the home setting. J Oncol Pharm Practice. 2017; 23:350–378.
  • 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 Pract. 2006; 12:83-90.
  • Chen H-C, Lu Z-YJ and Lee S-H. Nurses’ experiences in safe handling of chemotherapeutic agents: the Taiwan case. Cancer Nursing. 2016; 39:e29–38.
  • Connor TH, Celano P, Frame JN and Zan RT. Summary of the Workshop on the Safe Handling of Hazardous Drugs Cohosted by the National Institute for Occupational Safety and Health and the American Society of Clinical Oncology. J Oncol Pract 2017; 13:199-205.
  • Connor TH. Hazardous anticancer drugs in health care. 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.
  • 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 Pract. 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.
  • Eisenberg S. A call to action for hazardous drug safety: Where we have been and where we are going. Clin J Onc Nurs. 2016; 20: A1-A8.
  • Eisenberg S. Hazardous drugs and USP <800>: implications for nurses. Clin J Oncol Nurs. 2017; 21:179–187.
  • 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.
  • Gilani S and Giridharan S. Is it safe for pregnant health-care professionals to handle cytotoxic drugs? A review of the literature and recommendations. Ecancermedicalscience. 2014; 8:418.
  • 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 Pract. 2011; 17:68-80.
  • King J, Alexander M, Byrne J, MacMillan K, Mollo A, Kirsa S and Green M. A review of the evidence for occupational exposure risks to novel anticancer agents – A focus on monoclonal antibodies. J Oncol Pharm Pract. 2016;22(2):121-134.
  • Le Garlantezec P, Rizzo-Padoin N, Lamand V, Aupee O, Broto H and Almeras D. Handling of antineoplastic drugs in the hospital: focus on exposure and on protective measures (in French and English). Arch de Maladies Prof Environ. 2011; 72:24–35.
  • Lucas MA and Connor TH. Hazardous drugs: the silent stalker of healthcare workers? Training, education are key to preventing exposures. The Synergist. 2015; January:22-26.
  • Mathias Pl, Connor TH and B’Hymer C. A review of high performance liquid chromatographic-mass spectrometric urinary methods for anticancer drug exposure of health care workers. J Chromatography B 2017; 1060:316-324.
  • 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.
  • 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.
  • Meade E. Avoiding accidental exposure to intravenous cytotoxic drugs. Br J Nurs. 2014; 23:S34, S36-39.
  • 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.
  • Moore RM, Davis YM and Kaczmarek RG. An overview of occupational hazards among veterinarians, with particular reference to pregnant women. Am Ind Hyg Assoc J. 1993; 54:113-120.
  • Moretti M, Bonfiglioli R, Feretti D, Pavanello S, Mussi F, Grollino MG, Villarini M, Barbieri A, Ceretti E, Carrieri M, Buschini A, Appolloni M, Dominici L, Sabatini L, Gelatti U, Bartolucci GB, Poli P, Stronati L, Mastrangelo G and Monarca S. A study protocol for the evaluation of occupational mutagenic/carcinogenic risks in subjects exposed to antineoplastic drugs: a multicentric project. BMC Public Health. 2011; 11:195 (http:/Nrww.biomedcentral.com/1471-2458/11/195).
  • 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.
  • Polovich M and Giesker KE. Occupational hazardous drug exposure among non-oncology nurses. Medsurg Nurs. 2011; 20:79-85, 97.
  • Polovich M and Clark PC. Factors influencing oncology nurses’ use of hazardous drug safe-handling precautions. Oncol Nurs Forum. 2012; 39: E299-309.
  • Power LA. Hazardous drugs in oncology: the impact on practices of USP 797 and the NIOSH alert. Community Oncol. 2008; 5:343-346.
  • Power LA and Polovich M. Safe handling of hazardous drugs: reviewing standards for worker protection. Pharm Pract News 2016; Special Edition:23-36.
  • Rodier S, Saint Lorant G, Guilloit J-M, Palix A, Divanon F, Sichel F and Delépée R. Is hyperthermic intraperitoneal chemotherapy (HIPEC) safe for healthcare workers? Surg Oncol 2017; 26:242-251.
  • 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)
  • Roussel C and Connor TH. Chemotherapy: Biomarkers of exposure, effect, reproductive hazards, and cancer. The Oncology Pharmacist. 2014; 7:1, 10-13, 18.
  • Roussel C and Connor TH. Chemotherapy: current and emerging issues in safe handling of antineoplastic and other hazardous drugs. The Oncology Pharmacist. 2014; 7:1, 8-11. (Reprinted in The Oncology Nurse. 2014; 7:1, 14-17.)
  • 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.
  • Sewell GJ. The use of isolators for cytotoxic drug handling in hospital pharmacies. Eur J Parenteral Sci. 1999; 4:55–9.
  • Simon L, Halilou M-C, Gladief L, Gadiou M, Herin F, Hennebelle I, Chatelut E and Ferron G. Hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC): evaluation, prevention and policies to avoid occupational exposure for operating room personnel. Bull Cancer 2009; 96:971-977; doi: 10.1684/bdc.2009.0927. (French)
  • 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.
  • Sussman RG, Schatz AR, Kimmel TA, Ader A, Naumann BD and Weideman PA. Identifying and assessing highly hazardous drugs within quality risk management programs. Regul Toxicol Pharmacol. 2016; 79:S11–18.
  • 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).
  • Toolaram AP, Kummerer K and Schneider M. Environmental risk assessment of anti-cancer drugs and their transformation products: a focus on their genotoxicity characterization-state of knowledge and short comings. Mutat Res Rev Mutat Res. 2014; 760:18-35.
  • 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.
  • Vecchio D, Sasco AJ and Cann CI. Occupational risk in health care and research. Am J Ind Med. 2003; 43:36-397.
  • Walton AML, Eisenberg S and Friese CR. Hazardous drugs: legislative and regulatory efforts to improve safe handling. Clin J Oncol Nurs. 2017; 21:254–256.
  • Whitaker P. Occupational allergy to pharmaceutical products. Curr Opin Allergy Clin lmmunol 2016; 16:101-106.

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

  • Ahmad N, Simanovski V, Hertz S, Klaric G, Kaizer L and Krzyzanowska MK. Oral chemotherapy practices at Ontario cancer centres. J Oncol Pharm Pract. 2015; 21(4):249-257.
  • Alexander M, King J, Lingaratnam S, Byrne J, MacMillan K, Mollo A, Kirsa S and Green M. A survey of manufacturing and handling practices for monoclonal antibodies by pharmacy, nursing and medical personnel. J Oncol Pharm Pract. 2016; 22:219-227.
  • Al-Azzam SI, Awawdeh BT, Alzoubi KH, Khader YS and Alkafajei AM. Compliance with safer handling guidelines of antineoplastic drugs in Jordanian hospitals. J Oncol Pharm Pract. 2015; 21 (1):3-9.
  • Bayraktar-Ekincioglu A, Korubük G and Demirkan K.  An evaluation of chemotherapy drug preparation process in hospitals in Turkey: a pilot study. J Oncol Pharm Pract 2018; 24:563-573.
  • 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.
  • Boiano JM, Steege AL and Sweeney MH. Adherence to safe handling guidelines by health care workers who administer antineoplastic drugs. J Occup Environ Hyg. 2014; 11:728-740.
  • Boiano JM, Steege AL and Sweeney MH. Adherence to precautionary Guidelines for Compounding Antineoplastic Drugs: A Survey of Nurses and Pharmacy Practitioners. J Occup Environ Hyg. 2015; 12:588-602.
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Page last reviewed: January 30, 2019
Content source: National Institute for Occupational Safety and Health