The adverse health effects associated with antineoplastic agents (cancer
chemotherapy drugs, cytotoxic drugs) in cancer patients and some non-cancer
patients treated with these drugs are well documented. The very nature
of antineoplastic agents make them harmful to healthy cells and tissues
as well as the cancerous cells. For cancer patients with a life-threatening
disease, there is certainly a great benefit to treatment with these agents.
However, for the health care workers who are exposed to antineoplastic
agents as part of their work practice, precautions should be taken to
eliminate or reduce exposure as much as possible. Pharmacists who prepare
these drugs or nurses who may prepare and/or administer them are the two
occupational groups who have the highest potential exposure to antineoplastic
agents. Additionally, physicians and operating room personnel may also
be exposed through the treatment of patients. Hospital staff, such as
shipping and receiving personnel, custodial workers, laundry workers and
waste handlers, all have potential exposure to these drugs during the
course of their work. The increased use of antineoplastic agents in veterinary
oncology also puts these workers at risk for exposure to these drugs.
In addition to acute or short-term effects related to treatment with
antineoplastic agents, there are a number of long-term or chronic effects
that have been identified in patients. These include liver and kidney
damage, damage to the bone marrow, damage to the lungs and heart, infertility
(temporary and permanent), effects on reproduction and the developing
fetus in pregnant women, hearing impairment and cancer. The International
Agency for Research on Cancer (IARC) in Lyon, France has identified
a number of antineoplastic agents and two combination therapies as having
an association with cancer in patients who are treated with them. These
include both cancer and non-cancer patients. IARC currently lists eleven
agents and two combined therapies as Group 1 (Human carcinogens), twelve
as Group 2A (Probable human carcinogens) and eleven as Group 2B (Possible
human carcinogens).
A number of studies have documented environmental and worker exposure
to the antineoplastic agents. A variety of biological endpoints have been
used to evaluate worker exposure. These include, urine mutagenicity, chromosomal
damage, sister chromatid exchange, micronuclei induction, DNA damage,
HPRT mutations, and thioether excretion.
Additionally, analytical methods have been used to document worker exposure
to antineoplastic agents by measuring these drugs and/or their metabolites
in the urine of health care workers.
Similar analytical methods are currently being employed to measure the
level of environmental contamination in the workplace. Although the studies
on air sampling are limited, there have been numerous studies published
on environmental wipe sampling for these drugs.
In September, 2004, The National Institute for Occupational Safety and Health (NIOSH) published an Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings (DHHS (NIOSH) Publication No. 2004-165). This topic page is an expanded bibliography of related publications drawn from the published literature related to the Alert. Additional information on this topic can also be found on the NIOSH Hazardous Drug Exposures in Health Care topic page.
Publications, Guidelines, Review Articles and
Surveys
Recent Publications
This page contains articles published within the past three years on all
topics related to occupational exposure to antineoplastic agents. These
include articles on exposure studies, adverse health effects, evaluation
of protective equipment and guidelines for safe handling.
Guidelines, Recommendations and Regulations
for Handling Antineoplastic Agents
This page includes guideline for the safe handling of antineoplastic agents
from professional organizations, government agencies and international
groups. Links to relevant sites are included.
Review Articles
This page lists reviews of the literature published on the topic of safe
handling of antineoplastic agents which provide background information
on the topic.
Surveys
This page includes surveys conducted by researchers and organizations
on handling procedures used when working with antineoplastic drugs. The
surveys deal with work practice issues and compliance with published guidelines.
Effects of Occupational Exposure
Acute Effects
Many acute or short-term effects have been observed in patients treated
with antineoplastic agents. Some of these same effects have been seen
in health care workers who handle them. The acute effects associated with
exposure to antineoplastic agents, such as skin rashes, allergic-type
reactions, hair loss and others, are included in the publications listed
in this page.
Chronic Effects
Chronic or long-term effects of exposure to antineoplastic agents are
described in the articles listed in this page.
Effects on Fertility and Reproductive
Outcomes
The effects of antineoplastic agents on fertility and reproduction are
well documented in patients treated with these drugs. This page includes
articles published on the effect of exposure to antineoplastic agents
on fertility and reproduction, such as low birth weight, malformations
and others. Several studies have reported adverse reproductive outcomes
in female health care workers who were exposed to antineoplastic agents.
Association of Exposure to Antineoplastic
Agents with Cancer
Because many of the antineoplastic agents are known or suspected human
carcinogens, cancer is an area of concern when exposed to these agents.
Although limited, some information exists on the relationship of occupational
exposure to antineoplastic agents with cancer in health care workers.
Occupational Monitoring
Biological Studies
Several biological endpoints have
been employed to monitor health care workers’ exposure to antineoplastic
agents. Most of these endpoints measure various types of genotoxic damage.
Urinary Mutagenicity
Because many of the antineoplastic agents are mutagenic, studies have
employed methods to study the mutagenicity of urine as an indication of
exposure to these agents.
Chromosomal Aberrations
Chromosomal aberrations are known to be present in the cells of patients
treated with antineoplastic agents and have been used to monitor health care
workers exposed to these drugs.
Sister Chromatid Exchanges
Sister chromatid exchanges have been used as an indicator of exposure
to agents that cause DNA repair and are useful for monitoring health care
workers exposed to antineoplastic agents.
Micronuclei Induction
Micronuclei induction is another indicator of exposure to
DNA-damaging agents and has been used to monitor health care workers exposed
to antineoplastic agents.
DNA Damage
Direct damage to the DNA in the cells of health care workers is another
method that has been employed as an indicator of exposure to antineoplastic
agents.
HPRT Mutations
HPRT mutations in the cells of health care workers exposed to antineoplastic
agents has seen limited use as a method to monitor exposure.
Thioether Excretion
The excretion of thioethers in the urine is a non-specific indicator of
exposure to certain compounds and has been used in a small number of studies
to monitor health care workers exposed to antineoplastic agents.
Analytical Studies
Over the past several years, the
direct measurement of antineoplastic agents and/or their metabolites in
body fluids of health care workers has been employed to assess exposure
to these agents. Methods for a number of the more common agents are included
in the citations on this page. Currently, these techniques are only used
in research settings and not for routine monitoring of health care workers.
Urinary Excretion of Antineoplastic
Agents
Recently, sensitive methods have been developed to measure
specific antineoplastic agents in the urine of health care workers exposed
to these drugs.
Environmental Sampling, Decontamination, and
Protective Equipment
Environmental Sampling for Antineoplastic
Agents
Sensitive methods are currently available to measure specific antineoplastic
agents in surface wipe samples and air samples in the workplace environment.
Studies to date have focused more on wipe sampling than on air sampling
due to technical problems associated with air sampling methods for these
drugs.
Decontamination and Deactivation of
Antineoplastic Agents
Methods are available to chemically deactivate some of the
antineoplastic agents in order to reduce their toxicity.
Evaluation of Protective Equipment
for Handling Antineoplastic Agents
Various types of personal protective equipment have been evaluated for
reducing health care worker exposure to antineoplastic agents. These include
biological safety cabinets, gloves, protective gowns and closed-system
devices.
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Introduction