10.01.24

Protection against health hazards when handling cytostatics

As glad as we are today about the therapeutic effect of cytostatics in the treatment of cancer, they can be dangerous for healthy individuals. This article presents the appropriate measures and how to assess their effectiveness, as well as what is involved in professional removal.

When a patient is affected by cancer, various treatment methods such as surgical removal, radiation therapy, or chemotherapy are often employed, and they are frequently combined. In chemotherapy, the medication can interact with the DNA, RNA, or the protein synthesis of proliferating body cells. This disrupts the division or multiplication of cancer cells, which is the desired effect on cancer cells. Unfortunately, the same targets are applicable to both healthy and tumor cells, making the handling of cytostatics, also known as chemotherapy agents, so dangerous. This naturally poses a risk to healthy individuals who come into contact with these cytostatics, making them potentially hazardous to the health of healthy persons.

Upon contact with cytostatics, acute effects can include corrosive or irritant reactions, as well as damage to the eyes or irritation of the respiratory tract. Additionally, these substances are classified as CMR (Carcinogenic, Mutagenic, or Reproductive toxic) agents, which means they can be carcinogenic (C), cause genetic mutations (M), or have reproductive toxicity (R). Individuals exposed to these substances must be protected, and any potential hazards must be avoided. The central question now is:

How can healthy individuals be protected from health hazards with cytostatics?

How can healthy individuals be protected from health hazards with cytostatics? On one hand, organizational measures can be taken. This involves designing a concept to prevent hazards from A to Z, covering the entire process, including transportation, storage, disposal, and cleaning. Typically, this is done by the safety officer for occupational safety. It is generally recommended to ensure that as few healthy individuals as possible come into contact with cytostatics to minimize the risk to individuals. Minors, pregnant or lactating women should not have contact with cytostatics. All individuals handling cytostatics should receive training. This should not only include those who handle and administer them to patients but also maintenance and cleaning personnel. Training should cover relevant work techniques and appropriate cleaning procedures in theory and, ideally, practical training as well. It is important to tailor the training to the participants and their work environment, taking local conditions into account.

On the other hand, technical measures to prevent occupational diseases must also be implemented. This means providing a dedicated, clearly marked room for handling these substances, which should be lockable during the preparation and handling of cytostatics. The use of a safety cabinet (e.g., Class II according to DIN12980) or an isolator is recommended. Additionally, personal protective measures should be used, and occupational health measures should be taken preventively and in case of spillage.

To properly assess health hazards and evaluate the effectiveness of organizational and technical measures, the hazard must be systematically determined. This is done by evaluating exposure assessment using monitoring. The appropriate environmental monitoring with air quality measurements and surface swabs at suspected contamination points is the first step. Contamination points can be identified either by analyzing the (standardized) process or by comparing with similar workplaces. If you rely on the process, you need to analyze it for possible causes of contamination. This monitoring should be conducted over an extended period to identify anomalies over a longer period.

In addition to environmental monitoring, biomonitoring with exposed individuals is recommended. This can identify and assess the exposure and health hazards of individual persons. This then serves as a reference for occupational medical assessments following spills or other incidents. The following table provides a rough summary of the key points in bio and environmental monitoring:

The informativeness and, therefore, the quality of environmental monitoring are only as good as the appropriate selection of sampling locations and the frequency of when and where samples are taken for monitoring. In this regard, it is essential not only to consider the entire process, as in the concept development, but also other points that may pose a health risk due to contamination. Thus, throughout the entire process, from the delivery of cytostatics, storage, processing, to disposal, one must identify the exposed areas and simultaneously consider where and how they can be spread. The immediate surroundings, especially at the workstation, play a potentially hazardous role (e.g., the floor under the work surface), but the individual themselves can also pose a risk. They can unintentionally spread cytostatics through protective clothing or contact with the environment, such as phones, door handles, keyboards. The following diagram schematically illustrates what should be considered in the sampling strategy.

Even if you have established an excellent concept and comprehensive monitoring, it is essential to clean the workplace where cytostatics are processed. Cleaning should also be regularly trained or carried out by specialists. These cleaning training and the associated hygiene concept should also be workplace-specific and defined in a standard operating procedure (SOP). Often, this SOP prescribes cleaning with 0.1M sodium hydroxide or another alkaline cleaner, followed by two rinses with deionized water and subsequent disinfection with alcohol (e.g., 70% isopropanol). Again, it is important to consider the entire process and also clean the storage areas. Proper disposal and documentation of the cleaning process conclude this phase.

Cytostatics and chemotherapy are crucial and potent components in the fight against cancer. To protect people’s health from the risk of unintentional exposure, it is necessary to implement organizational and technical measures, introduce appropriate bio and environmental monitoring, systematically and repeatedly train the individuals involved, and establish professional cleaning procedures.

We are happy to help you with the removal of cytostatic drugs: Cytostatic removal | Enzler Hygiene AG.

References

• L. Weber: Gefahrstoff Zytostatikum. Onkologiepflege, 03, 2020

• S. Gnanasekaran, David Chaperon: Zytostatika-Entfernung: Warum es von Profis gemacht werden soll. Clinikum 4, 2023
• M. Jost, M. Rüegger, B. Liechti, A. Gutzwiller, Sicherer Umgang mit Zytostatika, Suva, 2/22
• Dr. André Heinemann, BGW- Bereich Gefahrstoffe und Toxikologie: Zytostatika im Gesundheitsdienst: Informationen zur sicheren Handhabung 02/2019
• Antje Heise: Zubereitung von Zytostatika in Apotheken: Untersuchungen zur Arbeitsplatzkontamination, Dissertation Ludwig-Maximilians-Universität zu München 2006