Occupational Exposure to Antineoplastic Agents

Recent Publications

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

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

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

Bonnabry P, Cingria L, Ackermann M, Sadeghipour F, Bilger L, 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.

Buchanan EC, Schneider PJ. 2009 Compounding Sterile Preparations 3rd Ed. http://www.ashp.org/bookstore/CompoundingSterilePrep/tabid/194/Default.aspx

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

Bussières JF, Theoret Y, Port-Labarthe, Larocque D. Program to monitor surface contamination by methotrexate in a hematology-oncology satellite pharmacy. Am J Health-Syst Pharm. 2007; 64:531-535.

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

Cavallo D., Ursini CL, Omodeo-Salé E, Iavicoli S. Micronucleus induction and FISH analysis in buccal cells and lymphocytes of nurses administering antineoplastic drugs. Mutat Res. 2007; 628:11-18.

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

Connor TH. Using PPE to prevent occupational exposure to antineoplastic and other hazardous drugs. Pharm Purchasing & Products. 2006, 2; 4-6.

Connor TH. Personal protective equipment for use in handling hazardous drugs. Pharm Purchasing & Products. 2006; 3:2-6.

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

Deng H, Lou, J, Zhang M, Wu W, Jin J, Chen S, Zheng W, Wang B, He J. Detecting the cytogenetic effects in workers occupationally exposed to vincristin with four genetic tests. Mutat Res. 2006; 599:152-159.

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

Fransman W, Huizer D, Tuerk J. Inhalation and dermal exposure t eight antineoplastic drugs in an industrial laundry facility. Int Arch Occup Environ Health. 2007; 80:396-403.

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

Fransman W, Roeleveld N, Peelen S, Kort de W, Kromhout H, Heedrik D. Nurses with dermal exposure to antineoplastic drugs Reproductive Outcomes. Epidemiology. 2007; 18:112-119

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

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

Guerbet M, Goullé JP, Lubrano J. Evaluation of the risk of contamination of surgical personnel by vaporization of oxaliplatin during the intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Eur J Surg Oncol. 2007; 33:623-629.

Harrison BR, Peters BG, Bing MR. Comparison of surface contamination with cyclophosphamide and fluorouracil using a closed-system drug transfer device versus standard preparation techniques. Am J Health-Syst Pharm. 2006; 63:1736-1744.

Hedmer M, Tinnerberg H, Axmon A, Joensson BAG. Environmental and biologocal monitoring of antineoplastic drugs in four workplaces in a Swedish hospital. Int Arch Occup Environ Health. 2008; 81:899-911

Ikeda K, Yagi Y, Tkegami M, Lu Y, Morimoto K, Kurokawa N. Efforts to ensure safety of hospital pharmacy personnel occupationally exposed to antineoplastic drugs during a preparation task. Hosp Pharm. 2007; 42:209-218.

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

Klancher JW, Vorndran M, Weiss W. Hazardous drugs. Professional Safety Nov 2008: 24-29.

Korinth G, Schmidt K., Midasch O, Boettcher M I, Angerer J, Drexler H. Investigations on permeation of mitomycin C through double layers of natural rubber gloves. Ann Occup Hyg. 2007; 51:593-600.

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

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

McDevitt MA, Condon M, Stamberg J, Karp JE, McDiarmid M. Fluorescent in situ hybridization (FISH) in bone marrow and peripheral blood of leukemia patients: Implications for occupational surveillance. Mutat Res. 2007; 629:24-31.

Labella CJ, Does your pharmacy have a compounding isolator? Am J Health-Syst Pharm. 2007; 64:855-858.

Nygren O. Wipe samples as a tool for monitoring aerosol deposition in workplaces. J Environ Monit. 2006; 8;49-52.

Nygren O, Olofsson E, Johansson L. Spill leakage using a drug preparing system based on double-filter technology. Ann Occup Hyg. 2008; 1-4.

Nyman H, Jorgenson J, Slawson MH. Workplace Contamination with Antineoplastic Agents in a new cancer hospital using a closed-system drug transfer device. Hosp Pharm. 2007; 42:219-225

Peters GF, McKeon, Weiss WT. Potential for airborne contamination in turbulent- and unidirectional-airflow compounding aseptic isolators. Am J Health-Syst Pharm. 2007; 64:622-631.

Rekhadevi PV, Sailaja N, Chandrasekhar M, Mahboob M, Rahman MF, Grover P. Genotoxicity assesment in oncology nurses handling anti-neoplastic drugs. Mutagenisis. 2007; 1-7.

Roberts S, Khammo N, McDonnell, Sewell GJ. Studies on the decontamination of surfaces exposed to cytotoxic drugs in chemotherapy workstations. J Oncol Pharm Practice. 2006; 12:95-104.

Rombaldi F, Cassini C, Salvador M, Saffi J, Erdtmann B. Occupational risk assessment of genotoxicyty and oxidative stress in workers handeling anti-neoplastic drugs during a work week. Mutagenesis. 2008; 1-6.

Sasaki M, Dakeishi M, Hoshi S, Ishii N, Murata K . Assessment of DNA damage in Japanese nurses handeling antineoplastic drugs by the comet assay. J Occup Health. 2008; 50:7-12.

Sottani C, Truci R, Schierl R, Gaggeri R, Barbieri A, Violante FS, Minoia C. Simultaneous determinatin of gemcitabine, taxol, cyclophosphamid and ifosphamid in wipe sampels by high-performance liquid chromatography/tandem mass spectrometry: protocol of validation and uncertainty of measurment. Rapid Commun Mass Spectrom. 2007; 21:1289:1296.

Testa A, Giachelia M, Palma S, Appolloni M, Padua L, Tranfo G, Spagnoli M, Trindelli D, Cozzi R. Occupational exposure to antineoplastic agents induces a high level of chromosome damage. Lack of an effect of GST polymorphisms. Tox and Appl Pharmacol. 2007; 223:46-55.

Touzin K, Bussières JF, Langlois É, Lefebvre M, Gallant C. Cyclophosphamide contamination observed on the surface of drug vials and the efficacy of cleaning on vial contamination. Ann Occup Hyg. 2008; 1-7.

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

Turci R, Sottani C, Schierl R, Minoia C. Validation protocol and analytical quality in biological monitoring of occupational exposure to antineoplastic drugs. Tox Lett. 2006; 162:256-262.

Tuerk J, Reinders M, Dryer M, Kiffmeyer TK, Schmidt KG, Kuss HM. Analysis of antibiotics in urine and wipe samples from environmental and biological monitoring- comparison of HPLC with UV-, single MS- and tandem MS-detection. J Chromatog. 2006; 831:72-80.

U.S. Pharmacopeia (USP) Revised Chapter (797) Pharmaceutical Compounding-Sterile Preparations. http://www.usp.org/USPNF/pf/generalChapter797.html

USP (797) Guidebook to Pharmaceutical Compounding-Sterile preparations

Wallemacq PE, Capron A, Vanbinst R, Boeckmans E, Gillard J, Favier B. Permeability of 13 different gloves to 13 cytotoxic agents under controlled dynamic conditions. Am J Health-Syst Pharm. 2006; 63:547-556.

Yoshida J, Kosaka H, Tomika K, Kumagai S. Genotoxic Risks to nurses from contamination of the work enviroment with antineoplastic drugs in Japan. J Occup Health; 2006; 48:517-522.

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.

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.

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. www.astm.org.

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, 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, Schneider PJ. 2009 Compounding Sterile Preparations 3rd Ed. http://www.ashp.org/bookstore/CompoundingSterilePrep/tabid/194/Default.aspx

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. 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.

Coyle B, 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.

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

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

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

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

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.

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. Standarts of Practice: Safe Handeling of Cytotoxics. J Oncol Pharm Practice. 2007; 13:1-81.

Jones RB, Frank R, 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, Weiss W. Hazardous drugs. 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, 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.

Massoomi F, Neff B, Rick A, 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.

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. Available:

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.

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. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN.aspx

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.

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.

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

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.

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. http://www.usp.org/USPNF/pf/generalChapter797.html

USP 797 Guidebook to Pharmaceutical Compounding-Sterile preparations

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

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

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

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

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

Piekarczyk A, Grzesiuk E, Zimak J, 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 abstarct)

Polovich M. Safe handling of hazardous drugs. Online Journal of Issues in Nursing. 2004; 9 (3)Manuscript 5. Available: www.nursingworld.org/ojin/topic25/tpc25_5.htm

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

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.

Gambrell J, 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

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.

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.