By Neil Patel, Abby Krupski, and Certina Ho

When individuals refer to chemotherapy (or chemo) for cancer treatment, they may think of receiving the drugs via an intravenous (IV) line at the hospital. Both healthcare professionals (HCPs) and patients may not be aware that some of them are available in oral dosage forms (i.e., taken by mouth). The availability of oral anti-cancer drugs has offered convenience to patients’ medication therapy management. However, many HCPs and patients may not realize that some of these drugs are hazardous* and they require safe handling throughout the medication-use process (e.g., manufacturer packaging, dispensing, administration, disposal, etc.). In 2016, approximately 79,000 Canadians are exposed to these drugs at work and 62% of them are pharmacy staff (https://www.carexcanada.ca/profile/antineoplastic_agents-occupational-exposures/). As such, safety measures should be in place to limit exposure for HCPs, patients, and caregivers. Pharmacists play a vital role in advancing safe use and handling of these medications in the health care system.

* Hazardous and Cytotoxic Drugs

It is important to note that all drugs have toxic or side effects, but the degree of toxicity could range from non-toxic to being toxic to patients at low doses, particularly, if not handled or used appropriately. According to the National Institute for Occupational Safety and Health (NIOSH) (https://www.cdc.gov/niosh/index.htm), a drug is considered hazardous if studies (involving humans or animals) have shown one or more of the following:

• Carcinogenicity i.e., causing cancer
• Teratogenicity or developmental toxicity i.e., causing congenital malformations
• Genotoxic i.e., causing mutations or damaging the DNA
• Reproductive toxicity i.e., affecting fertility (e.g., miscarriages, infertility)
• Organ toxicity at low doses (e.g., liver damage)
• Structure and toxicity profiles similar to existing hazardous drugs determined by the above criteria

Hazardous medications can cause toxicity or adverse effects to our health at low doses, and they include cytotoxic drugs. A cytotoxic drug can pose damaging action (e.g., carcinogenic, teratogenic, genotoxic, or mutagenic) on cells (including healthy cells) and includes most anti-cancer or chemo medication. Therefore, when handling hazardous and cytotoxic drugs, we should keep ourselves protected.

Sample “Hazardous” Scenarios

1. A patient crushes his Busulfan as he has trouble swallowing. Since he does not have a pill crusher, he decides to use the mortar and pestle in his kitchen. [Busulfan is commonly used to treat leukemias and lymphomas.]

• Safety in Administration: Busulfan is carcinogenic, teratogenic, genotoxic, and affects fertility. It should not be crushed. Crushing the pills can produce a fine dust that gets expelled into the air. This can be hazardous to anyone who breathes in the dust or gets in contact with their eyes, possibly absorbing the medication. The use of the shared mortar and pestle can inadvertently expose the drug to anyone who uses it afterwards. It is important to use a designated pill crusher that is not used in the kitchen due to the possibility of cross-contamination.

2. A patient on Cyclophosphamide is due for his dose. His pregnant wife who always manages his medications takes the medication out of its vial and hands it to her husband. She then carries on with her day. [Cyclophosphamide is commonly used to treat lung cancer, leukemias, lymphomas, and other types of cancer.]

• Caregiver Safety: Cyclophosphamide is carcinogenic, teratogenic, genotoxic, and affects fertility. It is not recommended for use in pregnancy. Special precautions should be taken to minimize the risk of a pregnant person (in this case, the caregiver) coming into contact with the medication. It is best if the patient can handle their medications themselves. If this is not feasible, caregivers can use medical gloves (latex or other alternatives) when handling the medication, disposing of them afterwards, and proceeding to wash their hands. (Note: Vinyl gloves are more permeable to hazardous drugs and hence are not)

3. A pharmacy assistant is preparing a prescription for 45 Methotrexate tablets; grabs the nearest pill-counting tray, counts the tablets, and put them in a vial. The assistant then proceeds to count the next patient’s Amlodipine (blood pressure medication) using the same pill-counting tray. [Methotrexate can be used to treat many types of cancer, e.g., breast or bladder cancers, but can also be used for rheumatoid arthritis or Crohn’s disease.]

• Safety in Healthcare Settings: Pharmacies should have a separate designated counting tray for cytotoxic medications. These trays should be cleaned with each use and non-cytotoxic medications should not be counted on these trays. Staff must take the same precautions as caregivers by using personal protective equipment (PPE) to keep themselves safe.

General Safe Handling Tips at Home

The risk of harm from handling hazardous and cytotoxic drugs is generally small, but it is best to avoid

exposure. Wash your hands with soap and water before and after handling these medications. The following is not a comprehensive list of tips. Refer to the NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings (https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016-161.pdf) and SickKids Safe Handling of Hazardous Medicine Learning Hub (https://www.aboutkidshealth.ca/safehandling) for further details.

Neil Patel and Abby Krupski are PharmD Students at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and Leslie Dan Faculty of Pharmacy, University of Toronto.

Readers can learn more about hazardous and cytotoxic drugs and their safe handling from:

• Cancer Care Ontario (CCO) Safe Handling of Hazardous Drugs (2022) (https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/2161)
• Canadian Association of Provincial Cancer Agencies (CAPCA) & CCO Recommendations for the Safe Use and Handling of Oral Anti-Cancer Drugs (OACDs) in Community Pharmacy: A Pan-Canadian Consensus Guideline (2017) (https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/38606)
• CAPCA Oral Cancer Drug Therapy Safe Use and Safe Handling Guidelines (2015) (https://capca.ca/wp-content/uploads/2020/10/En-Oral-Chemotherapy-Guideline-Final-11-May-2015.pdf)
• Safe Handling of Cytotoxics: Guideline Recommendations (2015) (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324350/pdf/conc-22-e27.pdf)