Perception, knowledge and protective practices for
surgical staff handling antineoplastic drugs during
HIPEC and PIPAC

Hubert Benoist, Clarisse Eveno, Sarah Wilson, Nicolas Vigneron, Jean-Marc
Guilloit, Remy Morello, Nicolas Simon, Pascal Odou, Guillaume Saint-Lorant

► To cite this version:

Hubert Benoist, Clarisse Eveno, Sarah Wilson, Nicolas Vigneron, Jean-Marc Guilloit, et al. Perception, knowledge and protective practices for surgical staff handling antineoplastic drugs during HIPEC and PIPAC. Pleura and peritoneum, 2022, 7 (2), pp.77-86. 10.1515/pp-2021-0151. hal-04420345

HAL Id: hal-04420345

https://normandie-univ.hal.science/hal-04420345

Submitted on 28 May 2024

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Distributed under a Creative Commons Attribution 4.0 International License
# Perception, knowledge and protective practices for surgical staff handling antineoplastic drugs during HIPEC and PIPAC

Hubert Benoist, Clarisse Eveno, Sarah Wilson, Nicolas Vigneron, Jean-Marc Guilloit, Remy Morello, Nicolas Simon, Pascal Odou, Guillaume Saint-Lorant

► To cite this version:

Hubert Benoist, Clarisse Eveno, Sarah Wilson, Nicolas Vigneron, Jean-Marc Guilloit, et al. Perception, knowledge and protective practices for surgical staff handling antineoplastic drugs during HIPEC and PIPAC. Pleura and peritoneum, 2022, 7 (2), pp.77-86. 10.1515/pp-2021-0151. hal-04420345

HAL Id: hal-04420345

https://normandie-univ.hal.science/hal-04420345v1

Submitted on 28 May 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
<figure><img src="image_2.png" /></figure>

Hubert Benoist*, Clarisse Eveno, Sarah Wilson, Nicolas Vigneron, Jean-Marc Guilloit, Rémy Morello, Nicolas Simon, Pascal Odou and Guillaume Saint-Lorant

# Perception, knowledge and protective practices for surgical staff handling antineoplastic drugs during HIPEC and PIPAC

https://doi.org/10.1515/pp-2021-0151

Received November 30, 2021; accepted March 13, 2022;
published online April 13, 2022

## Abstract

**Objectives:** Two surgical techniques used for peritoneal metastasis involve a risk of exposure to antineoplastic drugs (ADs): hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC). The objective of this study was to assess the differences in perception, training, and knowledge of the risks as well as in the protection practices and occupational exposures of all worker categories.

**Methods:** This descriptive study, led in two hospitals from two distant French regions, was performed through a face-to-face interview and assessed the perception, knowledge and handling practices of ADs by a questionnaire consisting of 52 questions.

**Results:** Fifty-one professionals participated in this survey. A total of 29.4% (n=15) professionals were afraid to handle ADs. Very few workers have been trained on handling ADs during initial training dedicated to all caregiver (5.9%; n=3). HIPEC is considered to involve a higher

risk of exposure to ADs than PIPAC (81.6% (n=31) vs. 57.9% (n=22), respectively, p=0.022, agreement 65.8%). Protective equipment is considered to be less suitable for HIPEC than for PIPAC (29% (n=11) vs. 10.5% (n=4), respectively, p=0.016, agreement 81.6%). Concerning the potential AD contamination location, the participants identified a significant difference between these two practices. During HIPEC, 15.7% (n=6) of caregivers indicated that they had negative symptoms perceived in their practice vs. 2.6% (n=1) during PIPAC.

**Conclusions:** This study shows that perception, knowledge and protection practices are different between HIPEC and PIPAC. It also shows a difference between the worker categories. In view of the difficulties in making operating room staff available, the related training programmes must have an adapted format.

**Keywords:** antineoplastic drugs; HIPEC; occupational risks; PIPAC.

## Introduction

Peritoneal metastasis is a disseminated cancer of the peritoneum with a poor prognosis and restricted therapeutic options [1, 2]. There are two alternative techniques to systemic antineoplastic drugs (ADs) to reduce systemic side effects owing to local homogeneous penetration into the tumour tissue: hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC).

The HIPEC technique consists of administering a bath of ADs into the abdominal cavity after cytoreductive surgery. The drugs are injected into the abdominal cavity at $42 \pm 1$ °C for a period of 30–90 min [3, 4]. The drugs used are mitomycin C for 60 min at 42 °C +/-1 °C, sometimes associated with cisplatin among others.

The PIPAC technique, developed by a German team [5], is a more recent technique. It consists of the injection of unheated ADs into the peritoneal cavity as an aerosol under pressure during laparoscopy. The therapeutic aerosol is maintained at 12 mmHg for 30 min at body temperature.

*Corresponding author: Dr. Hubert Benoist, PharmD, PhD Student, CHU de Caen, Department of Pharmacy, Avenue de la Côte de Nacre, CS30001, 14033 Caen, France; and Normandie Université, UNICAEN, UNIROUEN, ABTE, Centre de Lutte contre le Cancer F. Baclesse, Caen, France, Phone: +33 2 31 06 32 54, E-mail: hubertbenoist@gmail.com. https://orcid.org/0000-0003-1295-2191

Clarisse Eveno, Department of Digestive Surgery, CHU, Lille, France

Sarah Wilson, Nicolas Vigneron and Rémy Morello, CHU de Caen Normandie, Normandie Université, UNICAEN, Biostatistic and Clinical Research, Caen, France

Jean-Marc Guilloit, Department of Surgery, Comprehensive Cancer Center F. Baclesse, Caen, France

Nicolas Simon and Pascal Odou, Univ. Lille, CHU Lille, ULR 7365 – GRITA – Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France

Guillaume Saint-Lorant, Normandie Université, UNICAEN, UNIROUEN, ABTE, Centre de Lutte contre le Cancer F. Baclesse, Caen, France; and Univ. Lille, CHU Lille, ULR 7365 – GRITA – Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France. https://orcid.org/0000-0001-8429-6539

<figure><img src="image_3.png" /></figure>

<figure><img src="image_4.png" /></figure>
<figure><img src="image_2.png" /></figure>

Hubert Benoist*, Clarisse Eveno, Sarah Wilson, Nicolas Vigneron, Jean-Marc Guilloit, Rémy Morello, Nicolas Simon, Pascal Odou and Guillaume Saint-Lorant

# Perception, knowledge and protective practices for surgical staff handling antineoplastic drugs during HIPEC and PIPAC

https://doi.org/10.1515/pp-2021-0151

Received November 30, 2021; accepted March 13, 2022;
published online April 13, 2022

## Abstract

**Objectives:** Two surgical techniques used for peritoneal metastasis involve a risk of exposure to antineoplastic drugs (ADs): hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC). The objective of this study was to assess the differences in perception, training, and knowledge of the risks as well as in the protection practices and occupational exposures of all worker categories.

**Methods:** This descriptive study, led in two hospitals from two distant French regions, was performed through a face-to-face interview and assessed the perception, knowledge and handling practices of ADs by a questionnaire consisting of 52 questions.

**Results:** Fifty-one professionals participated in this survey. A total of 29.4% (n=15) professionals were afraid to handle ADs. Very few workers have been trained on handling ADs during initial training dedicated to all caregiver (5.9%; n=3). HIPEC is considered to involve a higher

risk of exposure to ADs than PIPAC (81.6% (n=31) vs. 57.9% (n=22), respectively, p=0.022, agreement 65.8%). Protective equipment is considered to be less suitable for HIPEC than for PIPAC (29% (n=11) vs. 10.5% (n=4), respectively, p=0.016, agreement 81.6%). Concerning the potential AD contamination location, the participants identified a significant difference between these two practices. During HIPEC, 15.7% (n=6) of caregivers indicated that they had negative symptoms perceived in their practice vs. 2.6% (n=1) during PIPAC.

**Conclusions:** This study shows that perception, knowledge and protection practices are different between HIPEC and PIPAC. It also shows a difference between the worker categories. In view of the difficulties in making operating room staff available, the related training programmes must have an adapted format.

**Keywords:** antineoplastic drugs; HIPEC; occupational risks; PIPAC.

## Introduction

Peritoneal metastasis is a disseminated cancer of the peritoneum with a poor prognosis and restricted therapeutic options [1, 2]. There are two alternative techniques to systemic antineoplastic drugs (ADs) to reduce systemic side effects owing to local homogeneous penetration into the tumour tissue: hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC).

The HIPEC technique consists of administering a bath of ADs into the abdominal cavity after cytoreductive surgery. The drugs are injected into the abdominal cavity at $42 \pm 1$ °C for a period of 30–90 min [3, 4]. The drugs used are mitomycin C for 60 min at 42 °C +/-1 °C, sometimes associated with cisplatin among others.

The PIPAC technique, developed by a German team [5], is a more recent technique. It consists of the injection of unheated ADs into the peritoneal cavity as an aerosol under pressure during laparoscopy. The therapeutic aerosol is maintained at 12 mmHg for 30 min at body temperature.

*Corresponding author: Dr. Hubert Benoist, PharmD, PhD Student, CHU de Caen, Department of Pharmacy, Avenue de la Côte de Nacre, CS30001, 14033 Caen, France; and Normandie Université, UNICAEN, UNIROUEN, ABTE, Centre de Lutte contre le Cancer F. Baclesse, Caen, France, Phone: +33 2 31 06 32 54, E-mail: hubertbenoist@gmail.com. https://orcid.org/0000-0003-1295-2191

Clarisse Eveno, Department of Digestive Surgery, CHU, Lille, France

Sarah Wilson, Nicolas Vigneron and Rémy Morello, CHU de Caen Normandie, Normandie Université, UNICAEN, Biostatistic and Clinical Research, Caen, France

Jean-Marc Guilloit, Department of Surgery, Comprehensive Cancer Center F. Baclesse, Caen, France

Nicolas Simon and Pascal Odou, Univ. Lille, CHU Lille, ULR 7365 – GRITA – Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France

Guillaume Saint-Lorant, Normandie Université, UNICAEN, UNIROUEN, ABTE, Centre de Lutte contre le Cancer F. Baclesse, Caen, France; and Univ. Lille, CHU Lille, ULR 7365 – GRITA – Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France. https://orcid.org/0000-0001-8429-6539

<figure><img src="image_3.png" /></figure>

<figure><img src="image_4.png" /></figure>
The ADs used are doxorubicin and cisplatin or oxaliplatin among others.

Concerning surface contamination, no standards exist regarding the acceptable or allowable surface concentrations of ADs in the healthcare setting. Surface contamination levels for cyclophosphamide in early studies led United States Pharmacopeia to describe a 1 ng/cm² level for cyclophosphamide, above which drug uptake was believed to occur [6]. For many years, the contamination of surfaces by ADs has been highlighted both in care units and in compounding units. Meijster et al. [7]. identified the different sectors potentially exposed to ADs, especially home care, nursing homes, pharmacies, laundries, waste treatment and pharmaceutical industries. In view of the risk of toxicity and contamination by ADs, healthcare workers must be particularly aware of the risks and respectful of protective practices. For nurses working in hospitals, exposure knowledge and perceived risk of harm from AD exposure were reported to be high, but the overall degree of caution exercised was low [8]. Previous studies have shown a gap between knowledge and protective practices such as using gloves [9, 10]. For staff performing HIPEC and PIPAC, perception and knowledge of the risks of handling ADs must be at the highest possible level given the data available about contamination. In the same way, the protection practices must be fully respected.

The objective of this study was to compare the differences in perception and knowledge of the risks associated with the practice of HIPEC and PIPAC, training, protection practices and occupational exposures of all staff by using questionnaires.

# Materials and methods

## Study setting

The study was led in two hospitals from two distant French regions. The first hospital has a range of the yearly number of HIPEC procedures done between 4 and 19 and a range between 6 and 11 for PIPAC procedures. The second hospital has a range of the yearly number of HIPEC procedures done between 20 and 34 and a range between 7 and 35 for PIPAC procedures. The caregivers were selected through recruitment among the operating room staff and signed a letter of informed consent.

## Questionnaire design

The questionnaire was approved by the local committee for the protection of the persons concerned (number A16-D49-VOL.30). Draft versions of the questionnaires were pretested on a small group of healthcare workers who did not participate in the research project. The

questionnaires included 52 questions and were divided into three major sections, namely, general questions, questions on HIPEC and questions on PIPAC, as presented in Appendix 1. The last two sections included questions on perception, knowledge, training on protection practices and occupational exposure. The finalized questionnaires first included participant characteristics such as gender, age and work experience. The first question which was general and related to risk perception was adapted from a survey led by Hon et al. [10] and had response options of “agree/disagree/don’t know”. The others questions, specific to risk perception during HIPEC and PIPEC had response options of very low to very important. The questions related to knowledge had response options of “agree/somewhat agree/somewhat disagree/disagree”, while the questions regarding training and knowledge of the existing procedures had more often a response options of “true/false/don’t know” adapted to the question. The questions related to risk handling practice and exposure practice had response options of “true/false”, while questions regarding personal protective equipment had response options of “always/sometimes/never”.

## Data collection

The questionnaires were administered during individual 20-min interviews led by two investigators, non-members of the surgical teams, who developed the questionnaire and consulted each other when in doubt. Interviews were not recorded so as not to create stress that could impact the answers to the questions. Carrying out the interview of caregiver during a break time and not on activity time. The survey was carried out between September 2019 and March 2020. Once all the questionnaires were collected, they were coded and input into EpiData version 3.1 software (EpiData association, Odense). All data were input by the same person other than the two investigators and were double-checked by an epidemiologist.

## Statistical analysis

General characteristics were primarily described for all the participants, then profession characteristics. The participants who performed both HIPEC and PIPAC were retained for paired analysis comparing their risk perception, knowledge and practices between the two procedures. The answers of these participants were then compared according to their profession. Qualitative variables were described with their effects and percentages and compared using the chi-squared test or Fisher's exact test if at least one of the expected values was lower than 5. Paired qualitative data were described with their effects and percentages and compared using the McNemar chi-square test, and their concordance was assessed by the agreement rate and Cohen's kappa. A kappa value ≤ 0.20 represents poor/slight agreement, from 0.21-0.40 indicates fair agreement, from 0.41-0.60 represents moderate agreement, from 0.61-0.80 means good agreement and ≥ 0.81 indicates excellent agreement. Quantitative variables were described by their mean, standard deviation and minimum and maximum. The means were compared using Student's t-test or paired Student's t-test for paired data. A p-value lower than 0.05 was considered significant. Data management and statistical analysis were performed using IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.
The ADs used are doxorubicin and cisplatin or oxaliplatin among others.

Concerning surface contamination, no standards exist regarding the acceptable or allowable surface concentrations of ADs in the healthcare setting. Surface contamination levels for cyclophosphamide in early studies led United States Pharmacopeia to describe a 1 ng/cm² level for cyclophosphamide, above which drug uptake was believed to occur [6]. For many years, the contamination of surfaces by ADs has been highlighted both in care units and in compounding units. Meijster et al. [7]. identified the different sectors potentially exposed to ADs, especially home care, nursing homes, pharmacies, laundries, waste treatment and pharmaceutical industries. In view of the risk of toxicity and contamination by ADs, healthcare workers must be particularly aware of the risks and respectful of protective practices. For nurses working in hospitals, exposure knowledge and perceived risk of harm from AD exposure were reported to be high, but the overall degree of caution exercised was low [8]. Previous studies have shown a gap between knowledge and protective practices such as using gloves [9, 10]. For staff performing HIPEC and PIPAC, perception and knowledge of the risks of handling ADs must be at the highest possible level given the data available about contamination. In the same way, the protection practices must be fully respected.

The objective of this study was to compare the differences in perception and knowledge of the risks associated with the practice of HIPEC and PIPAC, training, protection practices and occupational exposures of all staff by using questionnaires.

# Materials and methods

## Study setting

The study was led in two hospitals from two distant French regions. The first hospital has a range of the yearly number of HIPEC procedures done between 4 and 19 and a range between 6 and 11 for PIPAC procedures. The second hospital has a range of the yearly number of HIPEC procedures done between 20 and 34 and a range between 7 and 35 for PIPAC procedures. The caregivers were selected through recruitment among the operating room staff and signed a letter of informed consent.

## Questionnaire design

The questionnaire was approved by the local committee for the protection of the persons concerned (number A16-D49-VOL.30). Draft versions of the questionnaires were pretested on a small group of healthcare workers who did not participate in the research project. The

questionnaires included 52 questions and were divided into three major sections, namely, general questions, questions on HIPEC and questions on PIPAC, as presented in Appendix 1. The last two sections included questions on perception, knowledge, training on protection practices and occupational exposure. The finalized questionnaires first included participant characteristics such as gender, age and work experience. The first question which was general and related to risk perception was adapted from a survey led by Hon et al. [10] and had response options of “agree/disagree/don’t know”. The others questions, specific to risk perception during HIPEC and PIPEC had response options of very low to very important. The questions related to knowledge had response options of “agree/somewhat agree/somewhat disagree/disagree”, while the questions regarding training and knowledge of the existing procedures had more often a response options of “true/false/don’t know” adapted to the question. The questions related to risk handling practice and exposure practice had response options of “true/false”, while questions regarding personal protective equipment had response options of “always/sometimes/never”.

## Data collection

The questionnaires were administered during individual 20-min interviews led by two investigators, non-members of the surgical teams, who developed the questionnaire and consulted each other when in doubt. Interviews were not recorded so as not to create stress that could impact the answers to the questions. Carrying out the interview of caregiver during a break time and not on activity time. The survey was carried out between September 2019 and March 2020. Once all the questionnaires were collected, they were coded and input into EpiData version 3.1 software (EpiData association, Odense). All data were input by the same person other than the two investigators and were double-checked by an epidemiologist.

## Statistical analysis

General characteristics were primarily described for all the participants, then profession characteristics. The participants who performed both HIPEC and PIPAC were retained for paired analysis comparing their risk perception, knowledge and practices between the two procedures. The answers of these participants were then compared according to their profession. Qualitative variables were described with their effects and percentages and compared using the chi-squared test or Fisher's exact test if at least one of the expected values was lower than 5. Paired qualitative data were described with their effects and percentages and compared using the McNemar chi-square test, and their concordance was assessed by the agreement rate and Cohen's kappa. A kappa value ≤ 0.20 represents poor/slight agreement, from 0.21-0.40 indicates fair agreement, from 0.41-0.60 represents moderate agreement, from 0.61-0.80 means good agreement and ≥ 0.81 indicates excellent agreement. Quantitative variables were described by their mean, standard deviation and minimum and maximum. The means were compared using Student's t-test or paired Student's t-test for paired data. A p-value lower than 0.05 was considered significant. Data management and statistical analysis were performed using IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.
## Results

Fifty-one healthcare professionals participated in this study out of the 54 solicited (response rate: 94.4%) (Table 1A). There were 16 caregivers from one hospital and 35 from the other, representing 7 different occupational categories grouped into three major categories working in the operating room: medical staff (n=10), nursing staff (n=20) and auxiliary caregivers (n=21). The gender ratio M/F was 0.7. The majority of the health professionals surveyed worked in operating rooms during their hospital careers (Table 1A). The average length of employment was shorter for medical staff than for nursing staff due to the presence of assistants and residents in the medical staff. The average length of employment for auxiliary caregivers was fairly short, given their high turnover. Generally, outside the context of HIPEC and PIPAC, 29.4% (n=15) of healthcare professionals were afraid to handle ADs (Table 1B). Concerning fear, there was a significant difference among occupational workers (p=0.012), particularly in auxiliary caregivers. For the other questions, no significant differences were observed. We can notice that 15.7% of participants (n=8) thought that the toxicity risk level is the same for all ADs and 74.5% (n=38) thought that the safety measures currently in place sufficiently reduce the risk of contamination. For nursing staff and auxiliary staff, barely half of the respondents were confident that they can handle all situations with a potential risk of exposure, at 35% (n=7) and 52.0% (n=11), respectively. It is worth mentioning that very few staff have been trained on handling ADs during initial training dedicated to all occupational staff (5.9%, n=3). In addition, only 29.4% (n=15) were trained to handle ADs in their current place of work, with a mean period of 1.8

years since the last ongoing training program. In this survey, among the participants performing the two techniques (n=38), 76.3% (n=29) wished to be trained in the proper handling procedures for HIPEC and 71.0% (n=27) for PIPAC. Among respondents wanted to be trained on AD handling during HIPEC (n=29), 44.8% (n=13) would like to follow training in an academic lecture format and 20.7% (n=6) would like to follow distance e-learning training. For PIPAC, 51.8% (n=14) of respondents wanted to be trained (n=27) wished to follow a training course in an academic lecture format, while only 18.5% (n=5) wanted a distance e-learning course.

Comparing the differences in perceived risks associated with the practice of HIPEC and PIPAC (Table 2A), HIPEC is considered to have a higher risk of exposure to ADs than PIPAC (81.6% (n=31) vs. 57.9% (n=22), respectively, p=0.022, agreement 65.8%). In connection with this question, protective equipment is considered to be less suitable for HIPEC than for PIPAC (29 vs. 10.5%, respectively, p=0.016, agreement 81.6%). The risk of exposure is perceived as not being very low, especially for auxiliary caregivers in HIPEC, and is statistically significant among occupational categories for both HIPEC (p=0.018) and PIPAC (p=0.004) (Table 2B).

A significant difference can be observed between HIPEC and PIPAC in the ongoing training on the handling of ADs (p=0.039) (Table 3A) as well as between workers' categories in the PIPAC technique (p=0.010) (Table 3B). As complementary data to the Tables, 41.2% (n=21) of workers were not made aware of the correct procedure in case of accidental exposure to ADs, with a significant difference between worker categories (p=0.006): medical staff, n=5 (50%), nursing staff, n=3 (15%), auxiliary caregivers, n=13

<table><caption>**Table 1A:** Participants' characteristics.</caption><thead><tr><th></th><th></th><th>Overall</th><th>Medical staff</th><th>Nursing staff</th><th>Auxiliary caregivers</th></tr></thead><tbody><tr><td>Effectives, n (%)</td><td></td><td>51 (100)</td><td>10 (19.6)</td><td>20 (39.2)</td><td>21 (41.2)</td></tr><tr><td rowspan="2">Gender</td><td>Female, n (%)</td><td>30 (58.8)</td><td>3 (30)</td><td>13 (65)</td><td>14 (66.7)</td></tr><tr><td>Male, n (%)</td><td>21 (41.2)</td><td>7 (70)</td><td>7 (35)</td><td>7 (33.3)</td></tr><tr><td>Job tenure in the hospital, mean ± SD (range), months</td><td></td><td>137.6 ± 115.1 (2–467)</td><td>57.3 ± 74.5 (2–251)</td><td>160.4 ± 98.4 (7–419)</td><td>154.2 ± 131.9 (36–467)</td></tr><tr><td>Job tenure in operating rooms, mean ± SD (range), months</td><td></td><td>94.4 ± 72.1 (7–275)</td><td>75.7 ± 76.3 (12–251)</td><td>111.1 ± 79.9 (7–275)</td><td>87.5 ± 61.7 (24–251)</td></tr><tr><td>Mean job tenure in HIPEC, mean ± SD (range), months</td><td></td><td>43.8 ± 44.4 (1–168)</td><td>27.3 ± 44.5 (1–144)</td><td>68.1 ± 51.6 (7–168)</td><td>28.5 ± 23.2 (12–120)</td></tr><tr><td>Mean job tenure in PIPAC, mean ± SD (range), months</td><td></td><td>12.1 ± 11.1 (&lt;1–36)</td><td>12.3 ± 10.3 (1–24)</td><td>15.8 ± 13.2 (&lt;1–36)</td><td>7.8 ± 7.4 (4–24)</td></tr><tr><td>Age, mean ± SD (range), years</td><td></td><td>40.0 ± 9.3 (24–58)</td><td>35.3 ± 8.3 (27–56)</td><td>41.3 ± 7.4 (30–58)</td><td>41.1 ± 11.0 (24–57)</td></tr></tbody></table>
## Results

Fifty-one healthcare professionals participated in this study out of the 54 solicited (response rate: 94.4%) (Table 1A). There were 16 caregivers from one hospital and 35 from the other, representing 7 different occupational categories grouped into three major categories working in the operating room: medical staff (n=10), nursing staff (n=20) and auxiliary caregivers (n=21). The gender ratio M/F was 0.7. The majority of the health professionals surveyed worked in operating rooms during their hospital careers (Table 1A). The average length of employment was shorter for medical staff than for nursing staff due to the presence of assistants and residents in the medical staff. The average length of employment for auxiliary caregivers was fairly short, given their high turnover. Generally, outside the context of HIPEC and PIPAC, 29.4% (n=15) of healthcare professionals were afraid to handle ADs (Table 1B). Concerning fear, there was a significant difference among occupational workers (p=0.012), particularly in auxiliary caregivers. For the other questions, no significant differences were observed. We can notice that 15.7% of participants (n=8) thought that the toxicity risk level is the same for all ADs and 74.5% (n=38) thought that the safety measures currently in place sufficiently reduce the risk of contamination. For nursing staff and auxiliary staff, barely half of the respondents were confident that they can handle all situations with a potential risk of exposure, at 35% (n=7) and 52.0% (n=11), respectively. It is worth mentioning that very few staff have been trained on handling ADs during initial training dedicated to all occupational staff (5.9%, n=3). In addition, only 29.4% (n=15) were trained to handle ADs in their current place of work, with a mean period of 1.8

years since the last ongoing training program. In this survey, among the participants performing the two techniques (n=38), 76.3% (n=29) wished to be trained in the proper handling procedures for HIPEC and 71.0% (n=27) for PIPAC. Among respondents wanted to be trained on AD handling during HIPEC (n=29), 44.8% (n=13) would like to follow training in an academic lecture format and 20.7% (n=6) would like to follow distance e-learning training. For PIPAC, 51.8% (n=14) of respondents wanted to be trained (n=27) wished to follow a training course in an academic lecture format, while only 18.5% (n=5) wanted a distance e-learning course.

Comparing the differences in perceived risks associated with the practice of HIPEC and PIPAC (Table 2A), HIPEC is considered to have a higher risk of exposure to ADs than PIPAC (81.6% (n=31) vs. 57.9% (n=22), respectively, p=0.022, agreement 65.8%). In connection with this question, protective equipment is considered to be less suitable for HIPEC than for PIPAC (29 vs. 10.5%, respectively, p=0.016, agreement 81.6%). The risk of exposure is perceived as not being very low, especially for auxiliary caregivers in HIPEC, and is statistically significant among occupational categories for both HIPEC (p=0.018) and PIPAC (p=0.004) (Table 2B).

A significant difference can be observed between HIPEC and PIPAC in the ongoing training on the handling of ADs (p=0.039) (Table 3A) as well as between workers' categories in the PIPAC technique (p=0.010) (Table 3B). As complementary data to the Tables, 41.2% (n=21) of workers were not made aware of the correct procedure in case of accidental exposure to ADs, with a significant difference between worker categories (p=0.006): medical staff, n=5 (50%), nursing staff, n=3 (15%), auxiliary caregivers, n=13

<table><caption>**Table 1A:** Participants' characteristics.</caption><thead><tr><th></th><th></th><th>Overall</th><th>Medical staff</th><th>Nursing staff</th><th>Auxiliary caregivers</th></tr></thead><tbody><tr><td>Effectives, n (%)</td><td></td><td>51 (100)</td><td>10 (19.6)</td><td>20 (39.2)</td><td>21 (41.2)</td></tr><tr><td rowspan="2">Gender</td><td>Female, n (%)</td><td>30 (58.8)</td><td>3 (30)</td><td>13 (65)</td><td>14 (66.7)</td></tr><tr><td>Male, n (%)</td><td>21 (41.2)</td><td>7 (70)</td><td>7 (35)</td><td>7 (33.3)</td></tr><tr><td>Job tenure in the hospital, mean ± SD (range), months</td><td></td><td>137.6 ± 115.1 (2–467)</td><td>57.3 ± 74.5 (2–251)</td><td>160.4 ± 98.4 (7–419)</td><td>154.2 ± 131.9 (36–467)</td></tr><tr><td>Job tenure in operating rooms, mean ± SD (range), months</td><td></td><td>94.4 ± 72.1 (7–275)</td><td>75.7 ± 76.3 (12–251)</td><td>111.1 ± 79.9 (7–275)</td><td>87.5 ± 61.7 (24–251)</td></tr><tr><td>Mean job tenure in HIPEC, mean ± SD (range), months</td><td></td><td>43.8 ± 44.4 (1–168)</td><td>27.3 ± 44.5 (1–144)</td><td>68.1 ± 51.6 (7–168)</td><td>28.5 ± 23.2 (12–120)</td></tr><tr><td>Mean job tenure in PIPAC, mean ± SD (range), months</td><td></td><td>12.1 ± 11.1 (&lt;1–36)</td><td>12.3 ± 10.3 (1–24)</td><td>15.8 ± 13.2 (&lt;1–36)</td><td>7.8 ± 7.4 (4–24)</td></tr><tr><td>Age, mean ± SD (range), years</td><td></td><td>40.0 ± 9.3 (24–58)</td><td>35.3 ± 8.3 (27–56)</td><td>41.3 ± 7.4 (30–58)</td><td>41.1 ± 11.0 (24–57)</td></tr></tbody></table>
<table><caption>**Table 1B:** Participants' characteristics.</caption><thead><tr><th>Questions</th><th></th><th>Overall (n=51)</th><th>Medical staff (n=10)</th><th>Nursing staff (n=20)</th><th>Auxiliary caregivers (n=21)</th><th>p-Value</th></tr></thead><tbody><tr><td rowspan="2">Fear of handling AD [Q3]</td><td>Agree</td><td>15 (29.4)</td><td>1</td><td>3</td><td>11</td><td rowspan="2">0.012</td></tr><tr><td>Disagree</td><td>36 (70.6)</td><td>9</td><td>17</td><td>10</td></tr><tr><td rowspan="2">The toxicity risk level is the same for all AD [Q4]</td><td>Agree</td><td>8 (15.7)</td><td>2</td><td>4</td><td>2</td><td rowspan="2">0.598</td></tr><tr><td>Disagree + Don't know</td><td>43 (84.3)</td><td>8</td><td>16</td><td>19</td></tr><tr><td rowspan="2">The safety measures currently in place sufficiently reduce the risk of contamination [Q5]</td><td>Agree</td><td>38 (74.5)</td><td>8</td><td>15</td><td>15</td><td rowspan="2">1.000</td></tr><tr><td>Disagree + Don't know</td><td>13 (25.5)</td><td>2</td><td>5</td><td>6</td></tr><tr><td rowspan="2">I am confident that I can handle all situations with a potential risk of exposure to AD [Q6]</td><td>Agree</td><td>25 (49.0)</td><td>7</td><td>7</td><td>11</td><td rowspan="2">0.187</td></tr><tr><td>Disagree + Don't know</td><td>26 (51.0)</td><td>3</td><td>13</td><td>10</td></tr><tr><td rowspan="2">Initial training on the handling of AD (at nursing school, medical school, etc.) [Q7]</td><td>Yes</td><td>3 (5.9)</td><td>1</td><td>2</td><td>0</td><td rowspan="2">0.297</td></tr><tr><td>No</td><td>48 (94.1)</td><td>9</td><td>18</td><td>21</td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

<table><caption>**Table 2A:** Perception questions.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th colspan="3">Procedure performed</th><th colspan="3">Concordance</th></tr><tr><th>HIPEC (n=38)</th><th>PIPAC (n=38)</th><th>p-Value</th><th>Kappa</th><th>p-Value</th><th>Agreement</th></tr></thead><tbody><tr><td rowspan="2">Risk exposure assessment [Q13 Q31]</td><td>Very low</td><td>7</td><td>16</td><td rowspan="2"><strong>0.022</strong></td><td rowspan="2">0.240</td><td rowspan="2">0.108</td><td rowspan="2">65.8</td></tr><tr><td>≥ Low</td><td>31</td><td>22</td></tr><tr><td rowspan="2">Suitable protective equipment [Q14 Q32]</td><td>Agree</td><td>27</td><td>34</td><td rowspan="2"><strong>0.016</strong></td><td rowspan="2">0.448</td><td rowspan="2">0.005</td><td rowspan="2">81.6</td></tr><tr><td>Disagree + Don't know</td><td>11</td><td>4</td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

<table><caption>**Table 2B:** Perception questions by worker categories.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th colspan="4">Worker category n=38</th><th rowspan="2">p-Value</th></tr><tr><th>Medical staff (n=6)</th><th>Nursing staff (n=17)</th><th>Auxiliary caregivers (n=15)</th></tr></thead><tbody><tr><td rowspan="2">Risk exposure assessment for HIPEC [Q13]</td><td>Very low</td><td>3</td><td>4</td><td>0</td><td rowspan="2"><strong>0.018</strong></td></tr><tr><td>≥ Low</td><td>3</td><td>13</td><td>15</td></tr><tr><td rowspan="2">Risk exposure assessment for PIPAC [Q31]</td><td>Very low</td><td>5</td><td>9</td><td>2</td><td rowspan="2"><strong>0.004</strong></td></tr><tr><td>≥ Low</td><td>1</td><td>8</td><td>13</td></tr><tr><td rowspan="2">Is protective equipment suitable for HIPEC ? [Q14]</td><td>Agree</td><td>6</td><td>12</td><td>9</td><td rowspan="2">0.247</td></tr><tr><td>Disagree + Don't know</td><td>0</td><td>5</td><td>6</td></tr><tr><td rowspan="2">Is protective equipment suitable for PIPAC ? [Q32]</td><td>Agree</td><td>6</td><td>16</td><td>12</td><td rowspan="2">0.362</td></tr><tr><td>Disagree + Don't know</td><td>0</td><td>1</td><td>3</td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

(61.9%). They also did not know about the elimination procedure for ADs (p=0.037), particularly among nursing staff. Concerning the main potential routes of contamination perceived by the participants in the practice of HIPEC and PIPAC, significant differences were observed: workers identified the cutaneous route (92.1% (n=35) vs. 63.2% (n=24), p=0.003, agreement 65.8%) as well as the ocular route (81.6% (n=31) vs. 50.0% (n=19), p=0.002, agreement

63.2%) and the injectable route of contamination (57.9% (n=22) vs. 36.8% (n=14), p=0.008, agreement 78.9%) (Table 3A). More precisely, the non-medical category did not identify the cutaneous route during HIPEC practice (p=0.027) (Table 3B). Concerning the potential AD-contaminated location, the participants identified a significant difference between these two practices, namely, regarding contamination of the operating table
<table><caption>**Table 1B:** Participants' characteristics.</caption><thead><tr><th>Questions</th><th></th><th>Overall (n=51)</th><th>Medical staff (n=10)</th><th>Nursing staff (n=20)</th><th>Auxiliary caregivers (n=21)</th><th>p-Value</th></tr></thead><tbody><tr><td rowspan="2">Fear of handling AD [Q3]</td><td>Agree</td><td>15 (29.4)</td><td>1</td><td>3</td><td>11</td><td rowspan="2"><strong>0.012</strong></td></tr><tr><td>Disagree</td><td>36 (70.6)</td><td>9</td><td>17</td><td>10</td></tr><tr><td rowspan="2">The toxicity risk level is the same for all AD [Q4]</td><td>Agree</td><td>8 (15.7)</td><td>2</td><td>4</td><td>2</td><td rowspan="2">0.598</td></tr><tr><td>Disagree + Don't know</td><td>43 (84.3)</td><td>8</td><td>16</td><td>19</td></tr><tr><td rowspan="2">The safety measures currently in place sufficiently reduce the risk of contamination [Q5]</td><td>Agree</td><td>38 (74.5)</td><td>8</td><td>15</td><td>15</td><td rowspan="2">1.000</td></tr><tr><td>Disagree + Don't know</td><td>13 (25.5)</td><td>2</td><td>5</td><td>6</td></tr><tr><td rowspan="2">I am confident that I can handle all situations with a potential risk of exposure to AD [Q6]</td><td>Agree</td><td>25 (49.0)</td><td>7</td><td>7</td><td>11</td><td rowspan="2">0.187</td></tr><tr><td>Disagree + Don't know</td><td>26 (51.0)</td><td>3</td><td>13</td><td>10</td></tr><tr><td rowspan="2">Initial training on the handling of AD (at nursing school, medical school, etc.) [Q7]</td><td>Yes</td><td>3 (5.9)</td><td>1</td><td>2</td><td>0</td><td rowspan="2">0.297</td></tr><tr><td>No</td><td>48 (94.1)</td><td>9</td><td>18</td><td>21</td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

<table><caption>**Table 2A:** Perception questions.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th colspan="3">Procedure performed</th><th colspan="3">Concordance</th></tr><tr><th>HIPEC (n=38)</th><th>PIPAC (n=38)</th><th>p-Value</th><th>Kappa</th><th>p-Value</th><th>Agreement</th></tr></thead><tbody><tr><td rowspan="2">Risk exposure assessment [Q13 Q31]</td><td>Very low</td><td>7</td><td>16</td><td rowspan="2"><strong>0.022</strong></td><td rowspan="2">0.240</td><td rowspan="2">0.108</td><td rowspan="2">65.8</td></tr><tr><td>≥ Low</td><td>31</td><td>22</td></tr><tr><td rowspan="2">Suitable protective equipment [Q14 Q32]</td><td>Agree</td><td>27</td><td>34</td><td rowspan="2"><strong>0.016</strong></td><td rowspan="2">0.448</td><td rowspan="2">0.005</td><td rowspan="2">81.6</td></tr><tr><td>Disagree + Don't know</td><td>11</td><td>4</td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

<table><caption>**Table 2B:** Perception questions by worker categories.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th colspan="4">Worker category n=38</th><th rowspan="2">p-Value</th></tr><tr><th>Medical staff (n=6)</th><th>Nursing staff (n=17)</th><th>Auxiliary caregivers (n=15)</th></tr></thead><tbody><tr><td rowspan="2">Risk exposure assessment for HIPEC [Q13]</td><td>Very low</td><td>3</td><td>4</td><td>0</td><td rowspan="2"><strong>0.018</strong></td></tr><tr><td>≥ Low</td><td>3</td><td>13</td><td>15</td></tr><tr><td rowspan="2">Risk exposure assessment for PIPAC [Q31]</td><td>Very low</td><td>5</td><td>9</td><td>2</td><td rowspan="2"><strong>0.004</strong></td></tr><tr><td>≥ Low</td><td>1</td><td>8</td><td>13</td></tr><tr><td rowspan="2">Is protective equipment suitable for HIPEC ? [Q14]</td><td>Agree</td><td>6</td><td>12</td><td>9</td><td rowspan="2">0.247</td></tr><tr><td>Disagree + Don't know</td><td>0</td><td>5</td><td>6</td></tr><tr><td rowspan="2">Is protective equipment suitable for PIPAC ? [Q32]</td><td>Agree</td><td>6</td><td>16</td><td>12</td><td rowspan="2">0.362</td></tr><tr><td>Disagree + Don't know</td><td>0</td><td>1</td><td>3</td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

(61.9%). They also did not know about the elimination procedure for ADs (p=0.037), particularly among nursing staff. Concerning the main potential routes of contamination perceived by the participants in the practice of HIPEC and PIPAC, significant differences were observed: workers identified the cutaneous route (92.1% (n=35) vs. 63.2% (n=24), p=0.003, agreement 65.8%) as well as the ocular route (81.6% (n=31) vs. 50.0% (n=19), p=0.002, agreement

63.2%) and the injectable route of contamination (57.9% (n=22) vs. 36.8% (n=14), p=0.008, agreement 78.9%) (Table 3A). More precisely, the non-medical category did not identify the cutaneous route during HIPEC practice (p=0.027) (Table 3B). Concerning the potential AD-contaminated location, the participants identified a significant difference between these two practices, namely, regarding contamination of the operating table
<table><caption>**Table 3A:** Knowledge questions.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th colspan="3">Procedure performed (n=38)</th><th colspan="3">Concordance</th></tr><tr><th>HIPEC</th><th>PIPAC</th><th>p-Value</th><th>Kappa</th><th>p-Value</th><th>Agreement</th></tr></thead><tbody><tr><td rowspan="2">Ongoing training specific to this technique [Q15 Q33]</td><td>Yes</td><td>12</td><td>5</td><td><strong>0.039</strong></td><td>0.350</td><td>0.026</td><td>76.3</td></tr><tr><td>No</td><td>26</td><td>33</td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="12">Potential contamination by:</td><td>Injectable route [Q19a Q37g]</td><td>Agree</td><td>22</td><td>14</td><td><strong>0.008</strong></td><td>0.596</td><td>&lt;0.001</td><td>78.9</td></tr><tr><td></td><td>Disagree</td><td>16</td><td>24</td><td></td><td></td><td></td><td></td></tr><tr><td>Cutaneous route [Q19b Q37h]</td><td>Agree</td><td>35</td><td>24</td><td><strong>0.003</strong></td><td>0.121</td><td>0.548</td><td>65.8</td></tr><tr><td></td><td>Disagree</td><td>3</td><td>14</td><td></td><td></td><td></td><td></td></tr><tr><td>Inhaled route [Q19c Q37i]</td><td>Agree</td><td>22</td><td>25</td><td>0.607</td><td>0.169</td><td>0.315</td><td>60.5</td></tr><tr><td></td><td>Disagree</td><td>16</td><td>13</td><td></td><td></td><td></td><td></td></tr><tr><td>Ocular route [Q19d Q37j]</td><td>Agree</td><td>31</td><td>19</td><td><strong>0.002</strong></td><td>0.263</td><td>0.086</td><td>63.2</td></tr><tr><td></td><td>Disagree</td><td>7</td><td>19</td><td></td><td></td><td></td><td></td></tr><tr><td>Oral route [Q19e Q37k]</td><td>Agree</td><td>21</td><td>15</td><td>0.109</td><td>0.485</td><td>0.002</td><td>73.7</td></tr><tr><td></td><td>Disagree</td><td>17</td><td>23</td><td></td><td></td><td></td><td></td></tr><tr><td>Infusion bags [Q20a Q38a]</td><td>Agree</td><td>23</td><td>25</td><td>0.625</td><td>0.774</td><td>&lt;0.001</td><td>89.5</td></tr><tr><td></td><td>Disagree</td><td>15</td><td>13</td><td></td><td></td><td></td><td></td></tr><tr><td>Operating table [Q20d Q38d]</td><td>Agree</td><td>33</td><td>25</td><td><strong>0.039</strong></td><td>0.177</td><td>0.309</td><td>68.4</td></tr><tr><td></td><td>Disagree</td><td>5</td><td>13</td><td></td><td></td><td></td><td></td></tr><tr><td>Trolley surfaces [Q20e Q38e]</td><td>Agree</td><td>24</td><td>16</td><td>0.057</td><td>0.293</td><td>0.085</td><td>63.2</td></tr><tr><td></td><td>Disagree</td><td>14</td><td>22</td><td></td><td></td><td></td><td></td></tr><tr><td>Screen surfaces [Q20f Q38f]</td><td>Agree</td><td>21</td><td>14</td><td>0.143</td><td>0.129</td><td>0.506</td><td>55.3</td></tr><tr><td></td><td>Disagree</td><td>17</td><td>24</td><td></td><td></td><td></td><td></td></tr><tr><td>Ventilator [Q20g Q38g]</td><td>Agree</td><td>18</td><td>14</td><td>0.424</td><td>0.253</td><td>0.178</td><td>63.2</td></tr><tr><td></td><td>Disagree</td><td>20</td><td>24</td><td></td><td></td><td></td><td></td></tr><tr><td>Operating room telephone [Q20h Q38h]</td><td>Agree</td><td>22</td><td>19</td><td>0.508</td><td>0.526</td><td>0.002</td><td>76.3</td></tr><tr><td></td><td>Disagree</td><td>16</td><td>19</td><td></td><td></td><td></td><td></td></tr><tr><td>Computer keyboard [Q20i Q38i]</td><td>Agree</td><td>21</td><td>18</td><td>0.508</td><td>0.529</td><td>0.002</td><td>76.3</td></tr><tr><td></td><td>Disagree</td><td>17</td><td>20</td><td></td><td></td><td></td><td></td></tr><tr><td>Door detector [Q20j Q38j]</td><td>Agree</td><td>16</td><td>15</td><td>1.000</td><td>0.401</td><td>0.019</td><td>71.1</td></tr><tr><td></td><td>Disagree</td><td>22</td><td>23</td><td></td><td></td><td></td><td></td></tr><tr><td>Floor [Q20k Q38k]</td><td>Agree</td><td>36</td><td>29</td><td><strong>0.016</strong></td><td>0.304</td><td>0.055</td><td>81.6</td></tr><tr><td></td><td>Disagree</td><td>2</td><td>9</td><td></td><td></td><td></td><td></td></tr><tr><td>Walls [Q20l Q38l]</td><td>Agree</td><td>23</td><td>17</td><td>0.146</td><td>0.382</td><td>0.020</td><td>68.4</td></tr><tr><td></td><td>Disagree</td><td>15</td><td>21</td><td></td><td></td><td></td><td></td></tr><tr><td>Smoke evacuation system [Q20m Q38m]</td><td>Agree</td><td>23</td><td>22</td><td>1.000</td><td>0.510</td><td>0.003</td><td>76.3</td></tr><tr><td></td><td>Disagree</td><td>15</td><td>16</td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="2">Other [Q20n Q38o]</td><td>Yes</td><td>5</td><td>1</td><td>0.125</td><td>0.303</td><td>0.135</td><td>89.5</td></tr><tr><td>No</td><td>33</td><td>37</td><td></td><td></td><td></td><td></td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

(86.8% for HIPEC (n=33) vs. 65.8% for PIPAC (n=25), p=0.039, agreement 68.4%) and regarding contamination of the floor (94.7% for HIPEC (n=36) vs. 76.3% for PIPAC (n=29), p=0.016, agreement 81.6%) (Table 3A). More precisely, for HIPEC, the nursing staff and auxiliary caregivers did not identify any potential floor contamination, in contrast to the medical staff (p=0.022) (Table 3B). We can notice that for injectable route, there was a significant difference between worker categories (p=0.0001). For the other locations, no significant differences were observed for the different participants.

Concerning personal protective equipment (PPE), a tendency to wear specific gloves was observed, which was more frequent in HIPEC (97.3% (n=37) for HIPEC vs. 84.0% for PIPAC (n=32), p=0.063, agreement 86.8%) (Table 4A). The systematic wearing of specific masks was similar in both HIPEC and PIPAC practices; protective goggles were not systematically worn by workers for either surgical technique (65.7% for HIPEC (n=25) vs. 52.6% for PIPAC (n=20), respectively). Concerning general participants' characteristics (n=51), 54.9% (n=28) of the respondents indicated that they wear glasses. However, the wearing of a
<table><caption>**Table 3A:** Knowledge questions.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th colspan="3">Procedure performed (n=38)</th><th colspan="3">Concordance</th></tr><tr><th>HIPEC</th><th>PIPAC</th><th>p-Value</th><th>Kappa</th><th>p-Value</th><th>Agreement</th></tr></thead><tbody><tr><td rowspan="2">Ongoing training specific to this technique [Q15 Q33]</td><td>Yes</td><td>12</td><td>5</td><td><strong>0.039</strong></td><td>0.350</td><td>0.026</td><td>76.3</td></tr><tr><td>No</td><td>26</td><td>33</td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="12">Potential contamination by:</td><td>Injectable route [Q19a Q37g]</td><td>Agree</td><td>22</td><td>14</td><td><strong>0.008</strong></td><td>0.596</td><td>&lt;0.001</td><td>78.9</td></tr><tr><td></td><td>Disagree</td><td>16</td><td>24</td><td></td><td></td><td></td><td></td></tr><tr><td>Cutaneous route [Q19b Q37h]</td><td>Agree</td><td>35</td><td>24</td><td><strong>0.003</strong></td><td>0.121</td><td>0.548</td><td>65.8</td></tr><tr><td></td><td>Disagree</td><td>3</td><td>14</td><td></td><td></td><td></td><td></td></tr><tr><td>Inhaled route [Q19c Q37i]</td><td>Agree</td><td>22</td><td>25</td><td>0.607</td><td>0.169</td><td>0.315</td><td>60.5</td></tr><tr><td></td><td>Disagree</td><td>16</td><td>13</td><td></td><td></td><td></td><td></td></tr><tr><td>Ocular route [Q19d Q37j]</td><td>Agree</td><td>31</td><td>19</td><td><strong>0.002</strong></td><td>0.263</td><td>0.086</td><td>63.2</td></tr><tr><td></td><td>Disagree</td><td>7</td><td>19</td><td></td><td></td><td></td><td></td></tr><tr><td>Oral route [Q19e Q37k]</td><td>Agree</td><td>21</td><td>15</td><td>0.109</td><td>0.485</td><td>0.002</td><td>73.7</td></tr><tr><td></td><td>Disagree</td><td>17</td><td>23</td><td></td><td></td><td></td><td></td></tr><tr><td>Infusion bags [Q20a Q38a]</td><td>Agree</td><td>23</td><td>25</td><td>0.625</td><td>0.774</td><td>&lt;0.001</td><td>89.5</td></tr><tr><td></td><td>Disagree</td><td>15</td><td>13</td><td></td><td></td><td></td><td></td></tr><tr><td>Operating table [Q20d Q38d]</td><td>Agree</td><td>33</td><td>25</td><td><strong>0.039</strong></td><td>0.177</td><td>0.309</td><td>68.4</td></tr><tr><td></td><td>Disagree</td><td>5</td><td>13</td><td></td><td></td><td></td><td></td></tr><tr><td>Trolley surfaces [Q20e Q38e]</td><td>Agree</td><td>24</td><td>16</td><td>0.057</td><td>0.293</td><td>0.085</td><td>63.2</td></tr><tr><td></td><td>Disagree</td><td>14</td><td>22</td><td></td><td></td><td></td><td></td></tr><tr><td>Screen surfaces [Q20f Q38f]</td><td>Agree</td><td>21</td><td>14</td><td>0.143</td><td>0.129</td><td>0.506</td><td>55.3</td></tr><tr><td></td><td>Disagree</td><td>17</td><td>24</td><td></td><td></td><td></td><td></td></tr><tr><td>Ventilator [Q20g Q38g]</td><td>Agree</td><td>18</td><td>14</td><td>0.424</td><td>0.253</td><td>0.178</td><td>63.2</td></tr><tr><td></td><td>Disagree</td><td>20</td><td>24</td><td></td><td></td><td></td><td></td></tr><tr><td>Operating room telephone [Q20h Q38h]</td><td>Agree</td><td>22</td><td>19</td><td>0.508</td><td>0.526</td><td>0.002</td><td>76.3</td></tr><tr><td></td><td>Disagree</td><td>16</td><td>19</td><td></td><td></td><td></td><td></td></tr><tr><td>Computer keyboard [Q20i Q38i]</td><td>Agree</td><td>21</td><td>18</td><td>0.508</td><td>0.529</td><td>0.002</td><td>76.3</td></tr><tr><td></td><td>Disagree</td><td>17</td><td>20</td><td></td><td></td><td></td><td></td></tr><tr><td>Door detector [Q20j Q38j]</td><td>Agree</td><td>16</td><td>15</td><td>1.000</td><td>0.401</td><td>0.019</td><td>71.1</td></tr><tr><td></td><td>Disagree</td><td>22</td><td>23</td><td></td><td></td><td></td><td></td></tr><tr><td>Floor [Q20k Q38k]</td><td>Agree</td><td>36</td><td>29</td><td><strong>0.016</strong></td><td>0.304</td><td>0.055</td><td>81.6</td></tr><tr><td></td><td>Disagree</td><td>2</td><td>9</td><td></td><td></td><td></td><td></td></tr><tr><td>Walls [Q20l Q38l]</td><td>Agree</td><td>23</td><td>17</td><td>0.146</td><td>0.382</td><td>0.020</td><td>68.4</td></tr><tr><td></td><td>Disagree</td><td>15</td><td>21</td><td></td><td></td><td></td><td></td></tr><tr><td>Smoke evacuation system [Q20m Q38m]</td><td>Agree</td><td>23</td><td>22</td><td>1.000</td><td>0.510</td><td>0.003</td><td>76.3</td></tr><tr><td></td><td>Disagree</td><td>15</td><td>16</td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="2">Other [Q20n Q38o]</td><td>Yes</td><td>5</td><td>1</td><td>0.125</td><td>0.303</td><td>0.135</td><td>89.5</td></tr><tr><td>No</td><td>33</td><td>37</td><td></td><td></td><td></td><td></td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

(86.8% for HIPEC (n=33) vs. 65.8% for PIPAC (n=25), p=0.039, agreement 68.4%) and regarding contamination of the floor (94.7% for HIPEC (n=36) vs. 76.3% for PIPAC (n=29), p=0.016, agreement 81.6%) (Table 3A). More precisely, for HIPEC, the nursing staff and auxiliary caregivers did not identify any potential floor contamination, in contrast to the medical staff (p=0.022) (Table 3B). We can notice that for injectable route, there was a significant difference between worker categories (p=0.0001). For the other locations, no significant differences were observed for the different participants.

Concerning personal protective equipment (PPE), a tendency to wear specific gloves was observed, which was more frequent in HIPEC (97.3% (n=37) for HIPEC vs. 84.0% for PIPAC (n=32), p=0.063, agreement 86.8%) (Table 4A). The systematic wearing of specific masks was similar in both HIPEC and PIPAC practices; protective goggles were not systematically worn by workers for either surgical technique (65.7% for HIPEC (n=25) vs. 52.6% for PIPAC (n=20), respectively). Concerning general participants' characteristics (n=51), 54.9% (n=28) of the respondents indicated that they wear glasses. However, the wearing of a
<table><caption>**Table 3B:** Knowledge questions by worker categories.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th rowspan="2"></th><th colspan="4">Worker category (n=38)</th><th rowspan="2">p-Value</th></tr><tr><th>Medical staff (n=6)</th><th>Nursing staff (n=17)</th><th>Auxiliary caregivers (n=15)</th></tr></thead><tbody><tr><td rowspan="2">Ongoing training specific to this technique for HIPEC [Q15]</td><td></td><td>Yes</td><td>1</td><td>2</td><td>9</td><td rowspan="2">0.010</td></tr><tr><td></td><td>No</td><td>5</td><td>15</td><td>6</td></tr><tr><td rowspan="2">Ongoing training specific to this technique for PIPAC [Q33]</td><td></td><td>Yes</td><td>1</td><td>2</td><td>2</td><td rowspan="2">1.000</td></tr><tr><td></td><td>No</td><td>5</td><td>15</td><td>13</td></tr><tr><td rowspan="8">HIPEC potential contamination by:</td><td rowspan="2">Injectable route [Q19a]</td><td>Agree</td><td>3</td><td>7</td><td>12</td><td rowspan="2">0.084</td></tr><tr><td>Disagree</td><td>3</td><td>10</td><td>3</td></tr><tr><td rowspan="2">Cutaneous route [Q19b]</td><td>Agree</td><td>4</td><td>17</td><td>14</td><td rowspan="2">0.027</td></tr><tr><td>Disagree</td><td>2</td><td>0</td><td>1</td></tr><tr><td rowspan="2">Ocular route [Q19d]</td><td>Agree</td><td>4</td><td>15</td><td>12</td><td rowspan="2">0.478</td></tr><tr><td>Disagree</td><td>2</td><td>2</td><td>3</td></tr><tr><td rowspan="2">Operating table [Q20d]</td><td>Agree</td><td>4</td><td>16</td><td>13</td><td rowspan="2">0.216</td></tr><tr><td>Disagree</td><td>2</td><td>1</td><td>2</td></tr><tr><td rowspan="2">Floor [Q20k]</td><td>Agree</td><td>4</td><td>17</td><td>15</td><td rowspan="2">0.022</td></tr><tr><td>Disagree</td><td>2</td><td>0</td><td>0</td></tr><tr><td rowspan="8">PIPAC potential contamination by:</td><td rowspan="2">Injectable route [Q37g]</td><td>Agree</td><td>1</td><td>2</td><td>11</td><td rowspan="2">0.001</td></tr><tr><td>Disagree</td><td>5</td><td>15</td><td>4</td></tr><tr><td rowspan="2">Cutaneous route [Q37h]</td><td>Agree</td><td>2</td><td>10</td><td>12</td><td rowspan="2">0.129</td></tr><tr><td>Disagree</td><td>4</td><td>7</td><td>3</td></tr><tr><td rowspan="2">Ocular route [Q37j]</td><td>Agree</td><td>2</td><td>7</td><td>10</td><td rowspan="2">0.320</td></tr><tr><td>Disagree</td><td>4</td><td>10</td><td>5</td></tr><tr><td rowspan="2">Operating table [Q38d]</td><td>Agree</td><td>2</td><td>11</td><td>12</td><td rowspan="2">0.146</td></tr><tr><td>Disagree</td><td>4</td><td>6</td><td>3</td></tr><tr><td rowspan="2">Floor [Q38k]</td><td>Agree</td><td>3</td><td>12</td><td>14</td><td rowspan="2">0.075</td></tr><tr><td>Disagree</td><td>3</td><td>5</td><td>1</td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

gown varied significantly between these surgical practices (86.8% for HIPEC (n=33) vs. 63.2% for PIPAC (n=24), p=0.004, agreement 76.3%), with no difference between worker categories (Table 4B). Following the evaluation of protective practices, the exposure to antineoplastic drugs and the clinical signs felt during HIPEC and PIPAC were also investigated. During HIPEC, 6 healthcare professionals (15.7%) indicated that they had negative symptoms perceived in their current practice vs. one caregiver (2.6%) during PIPAC (Table 4A). These professionals had headaches, and one indicated that he also had skin signs. No surgeons who were closest to ADs reported any clinical signs. Five other professionals reported accidental exposure to ADs during these surgical techniques and did not experience any clinical signs during these accidental exposures.

Discussion

This study aimed at showing if there were differences in perception and knowledge of the risks associated with the

practice of HIPEC and PIPAC, training, protection practices and occupational exposures of all staff by using questionnaires. This multi-centre study showed a difference in safety perception and knowledge of the risk of exposure to ADs between HIPEC and PIPAC as well as between occupational categories, especially in the practice of HIPEC, which was considered by the participants to be riskier than PIPAC.

This study was conducted in two hospitals, a large academic hospital with versatility of activities and a smaller cancer-specific hospital corresponding to the two types of hospitals performing these procedures. For this study, there were few participants which can be explained by a specialized activity. However, the rate of participation in this questionnaire was very high (94.4%), i.e., almost all the operating room staff in the two centres. The questionnaires were conducted face-to-face and not by sending by post a self-administered questionnaire. A face-to-face questionnaire allows avoiding missing data. Such an interview can be stressful for the caregivers, but in the context of this study, the interviews were conducted during the same period by two investigators non-workers in the
<table><caption>Table 3B: Knowledge questions by worker categories.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th rowspan="2"></th><th colspan="4">Worker category (n=38)</th><th rowspan="2">p-Value</th></tr><tr><th>Medical staff (n=6)</th><th>Nursing staff (n=17)</th><th>Auxiliary caregivers (n=15)</th></tr></thead><tbody><tr><td rowspan="2">Ongoing training specific to this technique for HIPEC [Q15]</td><td></td><td>Yes</td><td>1</td><td>2</td><td>9</td><td rowspan="2">0.010</td></tr><tr><td></td><td>No</td><td>5</td><td>15</td><td>6</td></tr><tr><td rowspan="2">Ongoing training specific to this technique for PIPAC [Q33]</td><td></td><td>Yes</td><td>1</td><td>2</td><td>2</td><td rowspan="2">1.000</td></tr><tr><td></td><td>No</td><td>5</td><td>15</td><td>13</td></tr><tr><td rowspan="8">HIPEC potential contamination by:</td><td rowspan="2">Injectable route [Q19a]</td><td>Agree</td><td>3</td><td>7</td><td>12</td><td rowspan="2">0.084</td></tr><tr><td>Disagree</td><td>3</td><td>10</td><td>3</td></tr><tr><td rowspan="2">Cutaneous route [Q19b]</td><td>Agree</td><td>4</td><td>17</td><td>14</td><td rowspan="2">0.027</td></tr><tr><td>Disagree</td><td>2</td><td>0</td><td>1</td></tr><tr><td rowspan="2">Ocular route [Q19d]</td><td>Agree</td><td>4</td><td>15</td><td>12</td><td rowspan="2">0.478</td></tr><tr><td>Disagree</td><td>2</td><td>2</td><td>3</td></tr><tr><td rowspan="2">Operating table [Q20d]</td><td>Agree</td><td>4</td><td>16</td><td>13</td><td rowspan="2">0.216</td></tr><tr><td>Disagree</td><td>2</td><td>1</td><td>2</td></tr><tr><td rowspan="2">Floor [Q20k]</td><td>Agree</td><td>4</td><td>17</td><td>15</td><td rowspan="2">0.022</td></tr><tr><td>Disagree</td><td>2</td><td>0</td><td>0</td></tr><tr><td rowspan="8">PIPAC potential contamination by:</td><td rowspan="2">Injectable route [Q37g]</td><td>Agree</td><td>1</td><td>2</td><td>11</td><td rowspan="2">0.001</td></tr><tr><td>Disagree</td><td>5</td><td>15</td><td>4</td></tr><tr><td rowspan="2">Cutaneous route [Q37h]</td><td>Agree</td><td>2</td><td>10</td><td>12</td><td rowspan="2">0.129</td></tr><tr><td>Disagree</td><td>4</td><td>7</td><td>3</td></tr><tr><td rowspan="2">Ocular route [Q37j]</td><td>Agree</td><td>2</td><td>7</td><td>10</td><td rowspan="2">0.320</td></tr><tr><td>Disagree</td><td>4</td><td>10</td><td>5</td></tr><tr><td rowspan="2">Operating table [Q38d]</td><td>Agree</td><td>2</td><td>11</td><td>12</td><td rowspan="2">0.146</td></tr><tr><td>Disagree</td><td>4</td><td>6</td><td>3</td></tr><tr><td rowspan="2">Floor [Q38k]</td><td>Agree</td><td>3</td><td>12</td><td>14</td><td rowspan="2">0.075</td></tr><tr><td>Disagree</td><td>3</td><td>5</td><td>1</td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

gown varied significantly between these surgical practices (86.8% for HIPEC (n=33) vs. 63.2% for PIPAC (n=24), p=0.004, agreement 76.3%), with no difference between worker categories (Table 4B). Following the evaluation of protective practices, the exposure to antineoplastic drugs and the clinical signs felt during HIPEC and PIPAC were also investigated. During HIPEC, 6 healthcare professionals (15.7%) indicated that they had negative symptoms perceived in their current practice vs. one caregiver (2.6%) during PIPAC (Table 4A). These professionals had headaches, and one indicated that he also had skin signs. No surgeons who were closest to ADs reported any clinical signs. Five other professionals reported accidental exposure to ADs during these surgical techniques and did not experience any clinical signs during these accidental exposures.

Discussion

This study aimed at showing if there were differences in perception and knowledge of the risks associated with the

practice of HIPEC and PIPAC, training, protection practices and occupational exposures of all staff by using questionnaires. This multi-centre study showed a difference in safety perception and knowledge of the risk of exposure to ADs between HIPEC and PIPAC as well as between occupational categories, especially in the practice of HIPEC, which was considered by the participants to be riskier than PIPAC.

This study was conducted in two hospitals, a large academic hospital with versatility of activities and a smaller cancer-specific hospital corresponding to the two types of hospitals performing these procedures. For this study, there were few participants which can be explained by a specialized activity. However, the rate of participation in this questionnaire was very high (94.4%), i.e., almost all the operating room staff in the two centres. The questionnaires were conducted face-to-face and not by sending by post a self-administered questionnaire. A face-to-face questionnaire allows avoiding missing data. Such an interview can be stressful for the caregivers, but in the context of this study, the interviews were conducted during the same period by two investigators non-workers in the
<table><caption>**Table 4A:** Practice questions.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th colspan="3">Procedure performed (n=38)</th><th colspan="3">Concordance</th></tr><tr><th>HIPEC</th><th>PIPAC</th><th>p-Value</th><th>Kappa</th><th>p-Value</th><th>Agreement</th></tr></thead><tbody><tr><td>Bio-decontamination procedure</td><td>Yes</td><td>31</td><td>25</td><td>0.109</td><td>0.343</td><td>0.037</td><td>73.7</td></tr><tr><td>knowledge [Q21 Q39]</td><td>No + Don't know</td><td>7</td><td>13</td><td></td><td></td><td></td><td></td></tr><tr><td>If yes, can you explain it?</td><td>Yes</td><td>15</td><td>15</td><td>1.000</td><td>0.850</td><td>&lt;0.001</td><td>92.6</td></tr><tr><td></td><td>No</td><td>12</td><td>12</td><td></td><td></td><td></td><td></td></tr><tr><td>Wearing gloves [Q22 Q40]</td><td>Always</td><td>37</td><td>32</td><td>0.063</td><td>0.252</td><td>0.160</td><td>86.8</td></tr><tr><td></td><td>Not always</td><td>1</td><td>6</td><td></td><td></td><td></td><td></td></tr><tr><td>Wearing a mask [Q23 Q41]</td><td>Always</td><td>36</td><td>35</td><td>1.000</td><td>0.360</td><td>0.158</td><td>92.1</td></tr><tr><td></td><td>Not always</td><td>2</td><td>3</td><td></td><td></td><td></td><td></td></tr><tr><td>Wearing protective goggles [Q24 Q42]</td><td>Always</td><td>25</td><td>20</td><td>0.125</td><td>0.625</td><td>&lt;0.001</td><td>81.6</td></tr><tr><td></td><td>Not always</td><td>13</td><td>18</td><td></td><td></td><td></td><td></td></tr><tr><td>Wearing a gown [Q25 Q43]</td><td>Always</td><td>33</td><td>24</td><td><strong>0.004</strong></td><td>0.412</td><td>0.004</td><td>76.3</td></tr><tr><td></td><td>Not always</td><td>5</td><td>14</td><td></td><td></td><td></td><td></td></tr><tr><td>Mean annual number of interventions [Q26 Q44]</td><td>&lt;10</td><td>13</td><td>13</td><td>1.000</td><td>0.766</td><td>&lt;0.001</td><td>89.5</td></tr><tr><td></td><td>≥10</td><td>25</td><td>25</td><td></td><td></td><td></td><td></td></tr><tr><td>Bio-decontamination activity [Q27 Q45]</td><td>Yes</td><td>21</td><td>17</td><td>0.125</td><td>0.792</td><td>&lt;0.001</td><td>89.5</td></tr><tr><td></td><td>No</td><td>17</td><td>21</td><td></td><td></td><td></td><td></td></tr><tr><td>If yes, frequency of bio-decontamination</td><td>Each patient</td><td>14</td><td>15</td><td>1.000</td><td>-</td><td>-</td><td>94.1</td></tr><tr><td></td><td>Once a day</td><td>3</td><td>2</td><td></td><td></td><td></td><td></td></tr><tr><td>Use of a proper technique for bio-decontamination</td><td>Yes</td><td>14</td><td>14</td><td>1.000</td><td>1.000</td><td>0.065</td><td>100.0</td></tr><tr><td></td><td>No</td><td>1</td><td>1</td><td></td><td></td><td></td><td></td></tr><tr><td>Negative symptoms perceived when not exposed [Q28 Q46]</td><td>Yes</td><td>6</td><td>1</td><td>0.125</td><td>-0.047</td><td>1.000</td><td>81.6</td></tr><tr><td></td><td>No</td><td>32</td><td>37</td><td></td><td></td><td></td><td></td></tr><tr><td>Ever exposed to AD [Q29 Q47]</td><td>Yes</td><td>2</td><td>3</td><td>1.000</td><td>-0.067</td><td>1.000</td><td>86.8</td></tr><tr><td></td><td>No</td><td>36</td><td>35</td><td></td><td></td><td></td><td></td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

operating rooms and centres, during a break time and not during the activity time.

Protective equipment is considered to be less suitable for HIPEC than for PIPAC. Al Hosni et al. [11] assessed the awareness of the non-medical operating theatre staff concerning the risk of contamination. The authors found similar results, with half of the participants who believed that there was a moderate risk of exposure to ADs with HIPEC, while regarding PIPAC, this risk was estimated as

<table><caption>**Table 4B:** Practice questions by worker categories.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th colspan="5">Worker category n=38</th></tr><tr><th>Medical staff (n=6)</th><th>Nursing staff (n=17)</th><th>Auxiliary caregivers (n=15)</th><th>p-Value</th></tr></thead><tbody><tr><td rowspan="2">Wearing a gown [Q25]</td><td>Always</td><td>4</td><td>16</td><td>13</td><td rowspan="2">0.218</td></tr><tr><td>Not always</td><td>2</td><td>1</td><td>2</td></tr><tr><td rowspan="2">Wearing a gown [Q43]</td><td>Always</td><td>4</td><td>8</td><td>12</td><td rowspan="2">0.159</td></tr><tr><td>Not always</td><td>2</td><td>9</td><td>3</td></tr></tbody></table>

weak for 59.0% of the respondents. The risk of exposure was perceived as being not very low in both practices, especially for auxiliary caregivers, and was statistically significant between the occupational categories for both HIPEC and PIPAC. Clerc et al. [12] also showed that more than other worker categories, operating room cleaning staff perceived the main risks of AD exposure in HIPEC but not in PIPAC. The safety perceived for PIPAC could have various explanations. The amount and volume of drug used in PIPAC is up to 10-fold lower than that in HIPEC. During the PIPAC procedure, the chemotherapy liquid is aerosolized, unlike in the HIPEC procedure, where the ADs remains liquid. In open-abdomen HIPEC, called the coliseum technique, the chemotherapy drug is released in the open air, unlike in the closed abdomen technique. PIPAC is administered during laparoscopy, and the patient is placed under a plastic cover to avoid the risk of contamination in case of leakage. During the whole process of injection of ADs and the residence time during PIPAC, the operating staff is outside the operating room.

Knowledge of risk exposure was less perceived in PIPAC, particularly concerning perception of the main potential routes of contamination such as the cutaneous
<table><caption>**Table 4A:** Practice questions.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th colspan="3">Procedure performed (n=38)</th><th colspan="3">Concordance</th></tr><tr><th>HIPEC</th><th>PIPAC</th><th>p-Value</th><th>Kappa</th><th>p-Value</th><th>Agreement</th></tr></thead><tbody><tr><td>Bio-decontamination procedure knowledge [Q21 Q39]</td><td>Yes</td><td>31</td><td>25</td><td>0.109</td><td>0.343</td><td>0.037</td><td>73.7</td></tr><tr><td></td><td>No + Don't know</td><td>7</td><td>13</td><td></td><td></td><td></td><td></td></tr><tr><td>If yes, can you explain it?</td><td>Yes</td><td>15</td><td>15</td><td>1.000</td><td>0.850</td><td>&lt;0.001</td><td>92.6</td></tr><tr><td></td><td>No</td><td>12</td><td>12</td><td></td><td></td><td></td><td></td></tr><tr><td>Wearing gloves [Q22 Q40]</td><td>Always</td><td>37</td><td>32</td><td>0.063</td><td>0.252</td><td>0.160</td><td>86.8</td></tr><tr><td></td><td>Not always</td><td>1</td><td>6</td><td></td><td></td><td></td><td></td></tr><tr><td>Wearing a mask [Q23 Q41]</td><td>Always</td><td>36</td><td>35</td><td>1.000</td><td>0.360</td><td>0.158</td><td>92.1</td></tr><tr><td></td><td>Not always</td><td>2</td><td>3</td><td></td><td></td><td></td><td></td></tr><tr><td>Wearing protective goggles [Q24 Q42]</td><td>Always</td><td>25</td><td>20</td><td>0.125</td><td>0.625</td><td>&lt;0.001</td><td>81.6</td></tr><tr><td></td><td>Not always</td><td>13</td><td>18</td><td></td><td></td><td></td><td></td></tr><tr><td>Wearing a gown [Q25 Q43]</td><td>Always</td><td>33</td><td>24</td><td><strong>0.004</strong></td><td>0.412</td><td>0.004</td><td>76.3</td></tr><tr><td></td><td>Not always</td><td>5</td><td>14</td><td></td><td></td><td></td><td></td></tr><tr><td>Mean annual number of interventions [Q26 Q44]</td><td>&lt;10</td><td>13</td><td>13</td><td>1.000</td><td>0.766</td><td>&lt;0.001</td><td>89.5</td></tr><tr><td></td><td>≥10</td><td>25</td><td>25</td><td></td><td></td><td></td><td></td></tr><tr><td>Bio-decontamination activity [Q27 Q45]</td><td>Yes</td><td>21</td><td>17</td><td>0.125</td><td>0.792</td><td>&lt;0.001</td><td>89.5</td></tr><tr><td></td><td>No</td><td>17</td><td>21</td><td></td><td></td><td></td><td></td></tr><tr><td>If yes, frequency of bio-decontamination</td><td>Each patient Once a day</td><td>14</td><td>15</td><td>1.000</td><td>-</td><td>-</td><td>94.1</td></tr><tr><td>Use of a proper technique for bio-decontamination</td><td>Yes</td><td>14</td><td>14</td><td>1.000</td><td>1.000</td><td>0.065</td><td>100.0</td></tr><tr><td></td><td>No</td><td>1</td><td>1</td><td></td><td></td><td></td><td></td></tr><tr><td>Negative symptoms perceived when not exposed [Q28 Q46]</td><td>Yes</td><td>6</td><td>1</td><td>0.125</td><td>-0.047</td><td>1.000</td><td>81.6</td></tr><tr><td></td><td>No</td><td>32</td><td>37</td><td></td><td></td><td></td><td></td></tr><tr><td>Ever exposed to AD [Q29 Q47]</td><td>Yes</td><td>2</td><td>3</td><td>1.000</td><td>-0.067</td><td>1.000</td><td>86.8</td></tr><tr><td></td><td>No</td><td>36</td><td>35</td><td></td><td></td><td></td><td></td></tr></tbody></table>

The bold values indicate a significant difference p < 0.05.

operating rooms and centres, during a break time and not during the activity time.

Protective equipment is considered to be less suitable for HIPEC than for PIPAC. Al Hosni et al. [11] assessed the awareness of the non-medical operating theatre staff concerning the risk of contamination. The authors found similar results, with half of the participants who believed that there was a moderate risk of exposure to ADs with HIPEC, while regarding PIPAC, this risk was estimated as

<table><caption>**Table 4B:** Practice questions by worker categories.</caption><thead><tr><th rowspan="2">Questions</th><th rowspan="2"></th><th colspan="5">Worker category n=38</th></tr><tr><th>Medical staff (n=6)</th><th>Nursing staff (n=17)</th><th>Auxiliary caregivers (n=15)</th><th>p-Value</th></tr></thead><tbody><tr><td rowspan="2">Wearing a gown [Q25]</td><td>Always</td><td>4</td><td>16</td><td>13</td><td rowspan="2">0.218</td></tr><tr><td>Not always</td><td>2</td><td>1</td><td>2</td></tr><tr><td rowspan="2">Wearing a gown [Q43]</td><td>Always</td><td>4</td><td>8</td><td>12</td><td rowspan="2">0.159</td></tr><tr><td>Not always</td><td>2</td><td>9</td><td>3</td></tr></tbody></table>

weak for 59.0% of the respondents. The risk of exposure was perceived as being not very low in both practices, especially for auxiliary caregivers, and was statistically significant between the occupational categories for both HIPEC and PIPAC. Clerc et al. [12] also showed that more than other worker categories, operating room cleaning staff perceived the main risks of AD exposure in HIPEC but not in PIPAC. The safety perceived for PIPAC could have various explanations. The amount and volume of drug used in PIPAC is up to 10-fold lower than that in HIPEC. During the PIPAC procedure, the chemotherapy liquid is aerosolized, unlike in the HIPEC procedure, where the ADs remains liquid. In open-abdomen HIPEC, called the coliseum technique, the chemotherapy drug is released in the open air, unlike in the closed abdomen technique. PIPAC is administered during laparoscopy, and the patient is placed under a plastic cover to avoid the risk of contamination in case of leakage. During the whole process of injection of ADs and the residence time during PIPAC, the operating staff is outside the operating room.

Knowledge of risk exposure was less perceived in PIPAC, particularly concerning perception of the main potential routes of contamination such as the cutaneous
route or the ocular route. Therefore, staffs are potentially exposed to aerosol contamination such as in the PIPAC technique or cutaneous contamination. The results are particularly important for the risk of contamination as at least 41.2% of workers had not been made aware of the proper procedure in case of accidental exposure to ADs, with a significant difference between the categories of workers. The workers, particularly nursing staff, also did not know about the elimination procedure of ADs.

A review by Kyriazanos et al. [13] concerning the safety of the operating staff during the administration of HIPEC showed that this procedure can be safely performed with regard to occupational exposure of healthcare staff. Indeed, compliance with specific protective measures is a key factor in minimizing AD exposure. Ametsbichler et al. [14] showed that AD contamination on various operating room surfaces is widespread and can lead to a distribution of AD residues and that the air contamination was very low. The risk of exposure for PIPAC is very low if adequate safety and cleaning standards are respected. Indeed, this potential AD contamination appears to originate from contact with contaminated surfaces. Many studies in the literature have shown that ADs are still regularly detected on surfaces in healthcare centres despite the specific decontamination protocols implemented [15, 16]. In our study, workers underestimated the environmental contamination, particularly the nursing staff and auxiliary caregivers who did not identify the operating table as potentially contaminated in PIPAC or floor contamination in HIPEC, unlike medical staff. In HIPEC, platinum surface contamination was found on the operating table (1.9–15 pg/cm²), on the floor under the operating table both before HIPEC (3.7–82 pg/cm²) and after HIPEC (970–19,458 pg/cm²) and up to 5 m on the floor (max: 36 pg/cm²), on the surgeon's shoes (6.5–134 pg/cm²) and on the infusion bags (12–88 pg/cm²) [17]. Platinum surface contamination was also found on HIPEC devices, especially on the regulation knob, with a median of approximately 10 pg/cm² [18]. For PIPAC, surface contamination by platinum was found in the injector (median: 2.82 pg/cm²) and trocars (median: 9.42 pg/cm²) and to a lesser extent on the floor (median: 0.06 pg/cm²) [14]. These results were confirmed more precisely in another study, which was also published in 2018, with platinum contamination of up to 574 ng/wipe for the neck injector syringe holder after cleaning was done [19]. Noted that in a recent French study, no surface contamination with platinum compounds were detected during PIPAC and 25% of urine samples in the exposed caregivers group were contaminated with no statistical difference observed in samples collected before and after PIPAC [20].

The lack of knowledge of the contamination risk could be explained by the non-systematic wearing of specific PPE, such as protective goggles that were not systematically worn by workers for both surgical techniques. The wearing of a gown was significantly different between these surgical practices. In one of the largest surveys on health care workers in the United States performed in care units, Boiano et al. [21] found that safe handling practices were not always respected by nurses who administer ADs, even though guidelines have existed for some time. Recently, in the context of peritoneal metastasis, Al Hosni et al. [11] showed that chemotherapy was identified as an occupational risk for all caregivers and explained that the partial wearing of PPE was due to the presence of slips and lapses and by a lack of comfort.

However, professionals have reported accidental exposure to ADs during these surgical techniques. During HIPEC, healthcare professionals indicated that they had negative symptoms during their current practice, with one caregiver reporting headaches and skin signs during PIPAC. It is, however, a difficult argument to prove that the headaches reported by professionals during HIPEC are linked to exposure to ADs. Indeed, HIPEC is a long surgery. Perception of environmental safety among operating room staff participating in HIPEC was previously investigated by Ortega-Deballon et al. [22]. They observed that operating room staff reported having experienced noxious symptoms during open HIPEC procedures (55%) and that this incidence of symptoms fell to 17% after the introduction of the “semi-open” technique. The symptoms felt in the context of AD handling were previously investigated in care units [23–26]. Nevertheless, these accidental exposures should not be taken lightly, especially since our study shows a lack of knowledge of the exposure risk as well as defects in handling practices.

This study highlights a demand for training in the handling of ADs and protective measures. The participants wished to be trained in the proper procedures of AD handling. However, the response to questions regarding training dates is limited to the participants’ recollection and not to the real training dates. Al Hosni et al. [11] also highlighted the need for training in the context of HIPEC and PIPAC. Among those who would like to be trained, a majority of respondents would like to follow a training course in an academic lecture format. During the data collection and analysis of the results of the questionnaires, no causes for the choice of e-learning or academic lecture format were found for the minority of respondents who want to follow an e-learning course. Only 29.4% were trained to handle ADs in their current place of work, with a
route or the ocular route. Therefore, staffs are potentially exposed to aerosol contamination such as in the PIPAC technique or cutaneous contamination. The results are particularly important for the risk of contamination as at least 41.2% of workers had not been made aware of the proper procedure in case of accidental exposure to ADs, with a significant difference between the categories of workers. The workers, particularly nursing staff, also did not know about the elimination procedure of ADs.

A review by Kyriazanos et al. [13] concerning the safety of the operating staff during the administration of HIPEC showed that this procedure can be safely performed with regard to occupational exposure of healthcare staff. Indeed, compliance with specific protective measures is a key factor in minimizing AD exposure. Ametsbichler et al. [14] showed that AD contamination on various operating room surfaces is widespread and can lead to a distribution of AD residues and that the air contamination was very low. The risk of exposure for PIPAC is very low if adequate safety and cleaning standards are respected. Indeed, this potential AD contamination appears to originate from contact with contaminated surfaces. Many studies in the literature have shown that ADs are still regularly detected on surfaces in healthcare centres despite the specific decontamination protocols implemented [15, 16]. In our study, workers underestimated the environmental contamination, particularly the nursing staff and auxiliary caregivers who did not identify the operating table as potentially contaminated in PIPAC or floor contamination in HIPEC, unlike medical staff. In HIPEC, platinum surface contamination was found on the operating table (1.9–15 pg/cm²), on the floor under the operating table both before HIPEC (3.7–82 pg/cm²) and after HIPEC (970–19,458 pg/cm²) and up to 5 m on the floor (max: 36 pg/cm²), on the surgeon's shoes (6.5–134 pg/cm²) and on the infusion bags (12–88 pg/cm²) [17]. Platinum surface contamination was also found on HIPEC devices, especially on the regulation knob, with a median of approximately 10 pg/cm² [18]. For PIPAC, surface contamination by platinum was found in the injector (median: 2.82 pg/cm²) and trocars (median: 9.42 pg/cm²) and to a lesser extent on the floor (median: 0.06 pg/cm²) [14]. These results were confirmed more precisely in another study, which was also published in 2018, with platinum contamination of up to 574 ng/wipe for the neck injector syringe holder after cleaning was done [19]. Noted that in a recent French study, no surface contamination with platinum compounds were detected during PIPAC and 25% of urine samples in the exposed caregivers group were contaminated with no statistical difference observed in samples collected before and after PIPAC [20].

The lack of knowledge of the contamination risk could be explained by the non-systematic wearing of specific PPE, such as protective goggles that were not systematically worn by workers for both surgical techniques. The wearing of a gown was significantly different between these surgical practices. In one of the largest surveys on health care workers in the United States performed in care units, Boiano et al. [21] found that safe handling practices were not always respected by nurses who administer ADs, even though guidelines have existed for some time. Recently, in the context of peritoneal metastasis, Al Hosni et al. [11] showed that chemotherapy was identified as an occupational risk for all caregivers and explained that the partial wearing of PPE was due to the presence of slips and lapses and by a lack of comfort.

However, professionals have reported accidental exposure to ADs during these surgical techniques. During HIPEC, healthcare professionals indicated that they had negative symptoms during their current practice, with one caregiver reporting headaches and skin signs during PIPAC. It is, however, a difficult argument to prove that the headaches reported by professionals during HIPEC are linked to exposure to ADs. Indeed, HIPEC is a long surgery. Perception of environmental safety among operating room staff participating in HIPEC was previously investigated by Ortega-Deballon et al. [22]. They observed that operating room staff reported having experienced noxious symptoms during open HIPEC procedures (55%) and that this incidence of symptoms fell to 17% after the introduction of the “semi-open” technique. The symptoms felt in the context of AD handling were previously investigated in care units [23–26]. Nevertheless, these accidental exposures should not be taken lightly, especially since our study shows a lack of knowledge of the exposure risk as well as defects in handling practices.

This study highlights a demand for training in the handling of ADs and protective measures. The participants wished to be trained in the proper procedures of AD handling. However, the response to questions regarding training dates is limited to the participants’ recollection and not to the real training dates. Al Hosni et al. [11] also highlighted the need for training in the context of HIPEC and PIPAC. Among those who would like to be trained, a majority of respondents would like to follow a training course in an academic lecture format. During the data collection and analysis of the results of the questionnaires, no causes for the choice of e-learning or academic lecture format were found for the minority of respondents who want to follow an e-learning course. Only 29.4% were trained to handle ADs in their current place of work, with a
significant difference depending on the worker category in the PIPAC technique. The impact on practices of in-service training was previously studied in care units [9, 23, 27]. The different results of this study as well as the disparity between the worker categories show a need for a training programme that would be suited to the various work categories because the needs vary from one category to another.

## Conclusions

This study shows that perception, knowledge and protection practices vary between HIPEC and PIPAC. It also shows differences between these elements depending on the occupational categories. These results show the importance of implementing training programmes that tackle the contamination risks by ADs and take occupational categories into account. In view of the difficulties in making operating room staff available, the training programmes must have an adapted format using, for instance, simulation or e-learning. A better knowledge of the risks makes it easier to protect oneself properly.

**Acknowledgments:** The authors are grateful to A Goyer, N Delecourt, J Therasse, M-H Jumelle, D Mahiez and all participants of the questionnaires.

**Research funding:** None declared.

**Author contributions:** All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

**Competing interests:** Authors state no conflicts of interest with respect to the research, authorship, and/or publication of this article.

**Informed consent:** Informed consent was obtained from all individuals included in this study.

**Ethical approval:** Research involving human subjects complied with all relevant national regulations, institutional policies and is in accordance with the tenets of the Helsinki Declaration (as revised in 2013), and has been approved by the local committee for the protection of the persons concerned (number A16-D49-VOL.30).

## References

1. Klaver YL, Lemmens VE, Nienhuijs SW, Luyer MD, de Hingh IH. Peritoneal carcinomatosis of colorectal origin: incidence, prognosis and treatment options. World J Gastroenterol 2012;18: 5489-94.

2. Franko J, Shi Q, Meyers JP, Maughan TS, Adams RA, Seymour MT, et al. Prognosis of patients with peritoneal metastatic colorectal cancer given systemic therapy: an analysis of individual patient data from prospective randomised trials from the Analysis and Research in Cancers of the Digestive System (ARCAD) database. Lancet Oncol 2016;17:1709-19.

3. Sugarbaker PH. Intraperitoneal chemotherapy and cytoreductive surgery for the prevention and treatment of peritoneal carcinomatosis and sarcomatosis. Semin Surg Oncol 1998;14: 254-61.

4. Glehen O, Cotte E, Kusamura S, Deraco M, Baratti D, Passot G, et al. Hyperthermic intraperitoneal chemotherapy: nomenclature and modalities of perfusion. J Surg Oncol 2008;98:242-6.

5. Solass W, Hetzel A, Nadiradze G, Sagynaliev E, Reymond MA. Description of a novel approach for intraperitoneal drug delivery and the related device. Zentralbl Chir 2011;136:28.

6. USP general chapter <800> hazardous drugs handling in healthcare settings. 2017. https://www.usp.org/sites/default/files/usp/document/our-work/healthcare-quality-safety/general-chapter-800.pdf [Accessed 17 Apr 2021].

7. Meijster T, Fransman W, Veldhof R, Kromhout H. Exposure to antineoplastic drugs outside the hospital environment. Ann Occup Hyg 2006;50:657-64.

8. Polovich M, Clark PC. Factors influencing oncology nurses' use of hazardous drug safe-handling precautions. Oncol Nurs Forum 2012;39:E299-E309.

9. Kosgeroglu N, Ayranci U, Ozerdogan N, Demirustu C. Turkish nurses' information about, and administration of, chemotherapeutic drugs. J Clin Nurs 2006;15:1179-87.

10. Hon CY, Teschke K, Shen H. Health care workers' knowledge, perceptions, and behaviors regarding antineoplastic drugs: survey from British Columbia, Canada. J Occup Environ Hyg 2015; 12:669-77.

11. Al Hosni M, Rouget C, Cusumano C, Garcia Lozcano E, Popescu H, Carrere S, et al. Non-medical caregivers and the use of intraperitoneal chemotherapy in the operating theatre: a survey on the perception of safety. J Vis Surg 2020;157:461-7.

12. Clerc D, Hübner M, Ashwin KR, Somashekhar SP, Rau B, Ceelen W, et al. Current practice and perceptions of safety protocols for the use of intraperitoneal chemotherapy in the operating room: results of the IP-OR international survey. Pleura Peritoneum 2021; 6:39-45.

13. Kyriazanos I, Kalles V, Stefanopoulos A, Spiliotis J, Mohamed F. Operating personnel safety during the administration of hyperthermic intraperitoneal chemotherapy (HIPEC). Surg Oncol 2016;25:308-14.

14. Ametsbichler P, Böhlandt A, Nowak D, Schierl R. Occupational exposure to cisplatin/oxaliplatin during pressurized intraperitoneal aerosol chemotherapy (PIPAC)? Eur J Surg Oncol 2018;44:1793-9.

15. Poupeau C, Tanguay C, Caron NJ, Bussières JF. Multicenter study of environmental contamination with cyclophosphamide, ifosfamide, and methotrexate in 48 Canadian hospitals. J Oncol Pharm Pract 2018;24:9-17.

16. Ziegler E, Mason HJ, Baxter PJ. Occupational exposure to cytotoxic drugs in two UK oncology wards. Occup Environ Med 2002;59: 608-12.

17. Villa AF, El Balkhi S, Aboura R, Sageot H, Hasni-Pichard H, Pocard M, et al. Evaluation of oxaliplatin exposure of healthcare
significant difference depending on the worker category in the PIPAC technique. The impact on practices of in-service training was previously studied in care units [9, 23, 27]. The different results of this study as well as the disparity between the worker categories show a need for a training programme that would be suited to the various work categories because the needs vary from one category to another.

## Conclusions

This study shows that perception, knowledge and protection practices vary between HIPEC and PIPAC. It also shows differences between these elements depending on the occupational categories. These results show the importance of implementing training programmes that tackle the contamination risks by ADs and take occupational categories into account. In view of the difficulties in making operating room staff available, the training programmes must have an adapted format using, for instance, simulation or e-learning. A better knowledge of the risks makes it easier to protect oneself properly.

**Acknowledgments:** The authors are grateful to A Goyer, N Delecourt, J Therasse, M-H Jumelle, D Mahiez and all participants of the questionnaires.

**Research funding:** None declared.

**Author contributions:** All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

**Competing interests:** Authors state no conflicts of interest with respect to the research, authorship, and/or publication of this article.

**Informed consent:** Informed consent was obtained from all individuals included in this study.

**Ethical approval:** Research involving human subjects complied with all relevant national regulations, institutional policies and is in accordance with the tenets of the Helsinki Declaration (as revised in 2013), and has been approved by the local committee for the protection of the persons concerned (number A16-D49-VOL.30).

## References

1. Klaver YL, Lemmens VE, Nienhuijs SW, Luyer MD, de Hingh IH. Peritoneal carcinomatosis of colorectal origin: incidence, prognosis and treatment options. World J Gastroenterol 2012;18: 5489-94.

2. Franko J, Shi Q, Meyers JP, Maughan TS, Adams RA, Seymour MT, et al. Prognosis of patients with peritoneal metastatic colorectal cancer given systemic therapy: an analysis of individual patient data from prospective randomised trials from the Analysis and Research in Cancers of the Digestive System (ARCAD) database. Lancet Oncol 2016;17:1709-19.

3. Sugarbaker PH. Intraperitoneal chemotherapy and cytoreductive surgery for the prevention and treatment of peritoneal carcinomatosis and sarcomatosis. Semin Surg Oncol 1998;14: 254-61.

4. Glehen O, Cotte E, Kusamura S, Deraco M, Baratti D, Passot G, et al. Hyperthermic intraperitoneal chemotherapy: nomenclature and modalities of perfusion. J Surg Oncol 2008;98:242-6.

5. Solass W, Hetzel A, Nadiradze G, Sagynaliev E, Reymond MA. Description of a novel approach for intraperitoneal drug delivery and the related device. Zentralbl Chir 2011;136:28.

6. USP general chapter <800> hazardous drugs handling in healthcare settings. 2017. https://www.usp.org/sites/default/files/usp/document/our-work/healthcare-quality-safety/general-chapter-800.pdf [Accessed 17 Apr 2021].

7. Meijster T, Fransman W, Veldhof R, Kromhout H. Exposure to antineoplastic drugs outside the hospital environment. Ann Occup Hyg 2006;50:657-64.

8. Polovich M, Clark PC. Factors influencing oncology nurses' use of hazardous drug safe-handling precautions. Oncol Nurs Forum 2012;39:E299-E309.

9. Kosgeroglu N, Ayranci U, Ozerdogan N, Demirustu C. Turkish nurses' information about, and administration of, chemotherapeutic drugs. J Clin Nurs 2006;15:1179-87.

10. Hon CY, Teschke K, Shen H. Health care workers' knowledge, perceptions, and behaviors regarding antineoplastic drugs: survey from British Columbia, Canada. J Occup Environ Hyg 2015; 12:669-77.

11. Al Hosni M, Rouget C, Cusumano C, Garcia Lozcano E, Popescu H, Carrere S, et al. Non-medical caregivers and the use of intraperitoneal chemotherapy in the operating theatre: a survey on the perception of safety. J Vis Surg 2020;157:461-7.

12. Clerc D, Hübner M, Ashwin KR, Somashekhar SP, Rau B, Ceelen W, et al. Current practice and perceptions of safety protocols for the use of intraperitoneal chemotherapy in the operating room: results of the IP-OR international survey. Pleura Peritoneum 2021; 6:39-45.

13. Kyriazanos I, Kalles V, Stefanopoulos A, Spiliotis J, Mohamed F. Operating personnel safety during the administration of hyperthermic intraperitoneal chemotherapy (HIPEC). Surg Oncol 2016;25:308-14.

14. Ametsbichler P, Böhlandt A, Nowak D, Schierl R. Occupational exposure to cisplatin/oxaliplatin during pressurized intraperitoneal aerosol chemotherapy (PIPAC)? Eur J Surg Oncol 2018;44:1793-9.

15. Poupeau C, Tanguay C, Caron NJ, Bussières JF. Multicenter study of environmental contamination with cyclophosphamide, ifosfamide, and methotrexate in 48 Canadian hospitals. J Oncol Pharm Pract 2018;24:9-17.

16. Ziegler E, Mason HJ, Baxter PJ. Occupational exposure to cytotoxic drugs in two UK oncology wards. Occup Environ Med 2002;59: 608-12.

17. Villa AF, El Balkhi S, Aboura R, Sageot H, Hasni-Pichard H, Pocard M, et al. Evaluation of oxaliplatin exposure of healthcare
workers during heated intraperitoneal perioperative
chemotherapy (HIPEC). Ind Health 2015;53:28–37.

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

19. Ndaw S, Hanser O, Kenepekian V, Vidal M, Melczer M, Remy A, et al. Occupational exposure to platinum drugs during intraperitoneal chemotherapy. Biomonitoring and surface contamination. Toxicol Lett 2018;298:171–6.

20. Larroque M, Arnaudguilhem C, Bouyssiere B, Quenet F, Bouazza N, Jarlier M, et al. Evaluation of the environmental contamination and exposure risk in medical/non-medical staff after oxaliplatin- based pressurized intraperitoneal aerosol chemotherapy. Toxicol Appl Pharmacol 2021;15:115694.

21. Boiano JM, Steege AL, Sweeney MH. Adherence to safe handling guidelines by health care workers who administer antineoplastic drugs. J Occup Environ Hyg 2014;11:728–40.

22. Ortega-Deballon P, Facy O, Laluc G, Rousselet V, Giacomo GD, Chauffert B, et al. Enquête sur le sentiment de sécurité du personnel en fonction de la technique de chimiohyperthermie intrapéritonéale. Etude comparative entre méthode ouverte et semi-ouverte. J Chir 2010;147:79–83.

23. Turk M, Davas A, Ciceklioglu M, Sacaklioglu F, Mercan T. Knowledge, attitude and safe behaviour of nurses handling cytotoxic anticancer drugs in Ege University Hospital. Asian Pac J Cancer Prev APJCP 2004;5:164–8.

24. Kyprianou M, Kapsou M, Raftopoulos V, Soteriades ES. Knowledge, attitudes and beliefs of Cypriot nurses on the handling of antineoplastic agents. Eur J Oncol Nurs 2010;14: 278–82.

25. Valanis BG, Vollmer WM, Labuhn KT, Glass AG. Acute symptoms associated with antineoplastic drug handling among nurses. Cancer Nurs 1993;16:288–95.

26. Krstev S, Perunicić B, Vidaković A. Work practice and some adverse health effects in nurses handling antineoplastic drugs. Med Lav 2003;94:432–9.

27. DeJoy DM, Smith TD, Woldu H, Dyal MA, Steege AL, 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;14:485–93.

**Supplementary Material:** The online version of this article offers supplementary material (https://doi.org/10.1515/pp-2021-0151).
workers during heated intraperitoneal perioperative
chemotherapy (HIPEC). Ind Health 2015;53:28–37.

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

19. Ndaw S, Hanser O, Kenepekian V, Vidal M, Melczer M, Remy A, et al. Occupational exposure to platinum drugs during intraperitoneal chemotherapy. Biomonitoring and surface contamination. Toxicol Lett 2018;298:171–6.

20. Larroque M, Arnaudguilhem C, Bouyssiere B, Quenet F, Bouazza N, Jarlier M, et al. Evaluation of the environmental contamination and exposure risk in medical/non-medical staff after oxaliplatin- based pressurized intraperitoneal aerosol chemotherapy. Toxicol Appl Pharmacol 2021;15:115694.

21. Boiano JM, Steege AL, Sweeney MH. Adherence to safe handling guidelines by health care workers who administer antineoplastic drugs. J Occup Environ Hyg 2014;11:728–40.

22. Ortega-Deballon P, Facy O, Laluc G, Rousselet V, Giacomo GD, Chauffert B, et al. Enquête sur le sentiment de sécurité du personnel en fonction de la technique de chimiohyperthermie intrapéritonéale. Etude comparative entre méthode ouverte et semi-ouverte. J Chir 2010;147:79–83.

23. Turk M, Davas A, Ciceklioglu M, Sacaklioglu F, Mercan T. Knowledge, attitude and safe behaviour of nurses handling cytotoxic anticancer drugs in Ege University Hospital. Asian Pac J Cancer Prev APJCP 2004;5:164–8.

24. Kyprianou M, Kapsou M, Raftopoulos V, Soteriades ES. Knowledge, attitudes and beliefs of Cypriot nurses on the handling of antineoplastic agents. Eur J Oncol Nurs 2010;14: 278–82.

25. Valanis BG, Vollmer WM, Labuhn KT, Glass AG. Acute symptoms associated with antineoplastic drug handling among nurses. Cancer Nurs 1993;16:288–95.

26. Krstev S, Perunicić B, Vidaković A. Work practice and some adverse health effects in nurses handling antineoplastic drugs. Med Lav 2003;94:432–9.

27. DeJoy DM, Smith TD, Woldu H, Dyal MA, Steege AL, 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;14:485–93.

**Supplementary Material:** The online version of this article offers supplementary material (https://doi.org/10.1515/pp-2021-0151).