Safe Handling of Cytotoxic Drugs in Home Chemotherapy

HE EMERGENCE of outpatient chemotherapy and home chemotherapy as viable health care systems for the delivery of cancer treatment has been accompanied by a number of questions. Initially, the questions focused on dependable and feasible drug delivery equipment for outpatient and home settings. Subsequently, other questions arose. For instance, could the patient and supporting family members competently manage the doses, equipment, and potential side effects of outpatient and home chemotherapy? Now, with the systems for administering inpatient chemotherapy largely translated into outpatient and home settings, one question that remains unanswered is that of risks from handling antineoplastics to those other than patients-to the nurse in the clinic and home setting and to the supporting family members who have assumed direct care responsibilities. BACKGROUND While the benefits of antineoplastic drugs in cancer chemotherapy are well documented, many of these drugs cause secondary malignancies in patients. l-4 Since antineoplastic agents have been shown to be mutagenic, the probability exists that they will also be found to be carcinogenic.5 Reich6 observed that if antineoplastic agents are indeed carcinogenic, people who handle these drugs in delivering them to patients were possibly at risk from exposure. Research has indicated that health care workers who handle cytotoxic drugs may in fact be at risk for absorbing the drugs through mucous membranes, direct skin or eye contact, inhalation, or ingestion. Concern over such exposure has been raised because the most commonly used cytotoxic drugs have toxic effects including mutagenicity, teratogenicity, and carcinogenicity.7 Studies of the risks to health care providersnurses, pharmacists, and physician-f handling antineoplastic drugs have yielded conflicting results. Some findings were positive, while others were negative regarding the effects of occupational exposure to antineoplastic agents. These studies investigated a variety of possible effects of exposure: mutagenicity in urine of nurses who routinely prepared and administered these agents,8-‘2 sister chromatid exchange frequencies in lymphocytes of nurses who handled antineoplastic agents,13 chromosomal alterations in physicians and nurses handling the agents,14 urinary thioether excretion of exposed nurses, l5 liver damage in nurses after years of exposure,16 urine mutagenicity in pharmacists admixing agents,17,18 and spontaneous abortion among exposed nurses. l9 The conclusion that can be drawn from these studies is that the precise risk associated with low-level exposure to antineoplastic drugs is yet unknown. The studies do not conclusively confirm the health risk to personnel, nor do they conclusively dispel the possibility that risks are yet undetected. Furthermore, long-term effects cannot be challenged with current knowledge. No studies have been conducted to determine the occurrence of excess disease or disability among those who admix and administer these drugs. However, the weight of the evidence would lead to a prudent conclusion that protective measures be takenzO With no conclusive evidence regarding the ill effects of occupational exposure to antineoplastics , work in the area of protective devices and practices has continued. Researchers are currently investigating effective ways to detect and monitor the occurrence of exposure (Connor, personal communication, October 1988).21*22 Other research has examined the effectiveness of protective garments, such as gloves,23V24 and provided evidence of the relative protective qualities of the specific materials of gloves and gowns. Latex gloves have been found to be the least permeable. Safety hoods, nonaerosolizing venting devices, and deactivation chemicals also have been studied. To date, some answers are known, but many questions remain regarding protection of the health care provider.