Chemo Exposure Article

Quiksilver · Jul 21, 2010

http://invw.org/chemo-main

For those of you that may see it or may work with them every now and then. It is an interesting read.

I also find it interesting because I have been told very few manufacturers actually decontaminate bottles before they are shipped out of the warehouses to the distributers and ultimately to pharmacy staff.

I am also intrigued since even though these are now done in safety cabinets, how safe are they really? I mean people thought it were safe to do it on countertops, then it was thought to be safe in a laminar flow hood, and now who knows how safe it really is.

In the end I guess one can never be too careful around chemo

mustang sally · Jul 24, 2010

I saw this article online. I always thought I wanted to do oncology pharmacy, but this article definitely made me think twice.

rxlea · Jul 24, 2010

mustang sally said:
I saw this article online. I always thought I wanted to do oncology pharmacy, but this article definitely made me think twice.

The pharmacists don't usually prepare the chemos. The technicians do. I am sure there are some places that pharmacists prepare that stuff but, by and large, no. Also, keep in mind that these people were exposed to chemo before there were prep guidelines. I work with chemo just about everyday. We are required to gown up, wear special chemoprotective gloves, and work in a vertical flow hood. It is pretty safe. Prolonged exposure over many, many years could be a problem as there are still chemotherapy residues on most packaging and, in general, in the the vicinity where preparation takes place. However, if you're not doing it day in and day out for hours at a time, I would say you are not at that much of a risk. And, like I said, pharmacists don't usually do the preparing anyway...oncology pharmacists are usually up on the floors rounding with the docs and working out of their satellite pharmacy. In smaller clinics, they are verifying what the tech makes. Now, home health is probably an issue. Some mandatory guidelines need to be set up for sure, though.

EDIT: It is also the responsibility of the employer AND the employee to follow guidelines. most places have something in place and if they don't and you get a job there, you might want to mention it or just not work there if you are afraid of the risk.

spacecowgirl · Jul 24, 2010

I do very little mixing, mostly checking, and all of our preps are done in a barrier isolator. I feel quite safe working with it the small amount that I do and would feel safe even if I was doing more of the preps. It seems like working in manufactering would be more dangerous than mixing.

I try to be careful of course, but I don't worry too much about it. I probably encounter more carcinogens out of the chemo hood and I've already had cancer so...

CaptainPicard · Jul 25, 2010

rxlea said:
The pharmacists don't usually prepare the chemos. The technicians do.

I would like to know if this is true. I've only seen a few institutions so far, but at all of them, nobody but one or two of the pharmacists would prep chemo. All other IV room work was done by techs.

Its Z · Jul 25, 2010

This controversial thread deserves a mention..

rxlea · Jul 25, 2010

Its Z said:
This controversial thread deserves a mention..

Funny...you were talking about HR even back then.

rxlea · Jul 25, 2010

CaptainPicard said:
I would like to know if this is true. I've only seen a few institutions so far, but at all of them, nobody but one or two of the pharmacists would prep chemo. All other IV room work was done by techs.

Really? Hmm...wonder if it is a regional thing because here in AZ, seems like the techs do most of it.

Its Z · Jul 25, 2010

rxlea said:
Funny...you were talking about HR even back then.

I've been doing HR stuff when y'all were in diapers.

Corolla11 · Jul 25, 2010

Everyone's job kills them eventually.

aboveliquidice · Jul 25, 2010

Corolla11 said:
Everyone's job kills them eventually.

Not like this though...

I remember reading a cardinal newsletter (I think) that stated those with the greatest exposure to chemo agents were the pharmacy warehouse managers at each hospital. Chemo prep is very safe if your team is well trained. At Shands @ UF, the process was very scripted. Chemo pharmacist wrote out all of the orders to be filled for each patient. At the appropriate time, the chemo technician would prepare the chemo in the vertical flow hood. A 2nd tech (also trained on chemo) would verify the chemo was accurate. One of the IV pharmacists (there were 4 or 5 working the shift) would verify it for accuracy (triple check) as the final check. Then the pharmacist would watch the technician finish the prep (ie shooting into the bag) and bag the IV.

I miss working at Shands... something about being highspeed low drag.

Requiem · Jul 25, 2010

So do we have any evidence with regard to low level exposure of cyclo/ 5-FU at the workplace? Our workplace tested positive for "minute amounts" of a microgram per 10 cm^2 or some such for cyclo, 5FU, etc...

HR Said there's no conclusive data or good data following people and exposures to carcinogens or how they're doing 20 years later. If you're pregnant/breast feeding or a male and wanting to have a kid you're allowed to bypass doing chemo, so they acknowledge it. Blood tests to monitor for dyscrasias etc. are "voluntary" and we aren't even following people at our institution as they tout the lack of data. The only mandatory blood work is at baseline, which is pre-exposure and therefore of no use in and of itself.

Anyone done any research with regard to any evidence of population outcomes in those who are exposed at workplace vs those who aren't?

A pregnant lady asked about the potential risk to the fetus - he replied "we don't have any good data about the possibilities of damage" and likened it to the fact you still pump gas but hydrocarbons also can cause cancer.

Apparently there's a group out of the US which has demonstrated some chromosomal abnormalities (5 and 11 if im not mistaken), but the effect of which has not yet been discovered.

rxlea · Jul 25, 2010

At our hospital the doc writes out the order, one pharmacist enters it, another one verifies it, technician gets order and verifies it (I usually double check the calculations because one time I caught something and now I am extremely paranoid), technician preps it, another pharmacist checks order and watches the tech shoot in the drug, drug goes to the floor and the nurse checks it, another nurse double checks what that nurse is doing and there are always two nurses there when a bag is hung. The nurses have to be chemo certified (as do the techs)

Quiksilver · Jul 26, 2010

Its Z said:
This controversial thread deserves a mention..

I agree with you 100%. I would go so far to extend that to young males as well.

CaptainPicard said:
I would like to know if this is true. I've only seen a few institutions so far, but at all of them, nobody but one or two of the pharmacists would prep chemo. All other IV room work was done by techs.

all of the chemo at my place is made by techs or interns. Pharmacists make little if any chemo since the policy would require another pharmacist to check the first's work. Its this that scares me, technicians do not appreciate the care that must be taken to minimize exposure. I know some pharmacists may have the same neglectful practices but I think its more likely with techs.

Maybe its not the actual making of chemo thats the problem, maybe more exposure occurs post-check.

Requiem said:
So do we have any evidence with regard to low level exposure of cyclo/ 5-FU at the workplace? Our workplace tested positive for "minute amounts" of a microgram per 10 cm^2 or some such for cyclo, 5FU, etc...

HR Said there's no conclusive data or good data following people and exposures to carcinogens or how they're doing 20 years later. If you're pregnant/breast feeding or a male and wanting to have a kid you're allowed to bypass doing chemo, so they acknowledge it. Blood tests to monitor for dyscrasias etc. are "voluntary" and we aren't even following people at our institution as they tout the lack of data. The only mandatory blood work is at baseline, which is pre-exposure and therefore of no use in and of itself.

Anyone done any research with regard to any evidence of population outcomes in those who are exposed at workplace vs those who aren't?

A pregnant lady asked about the potential risk to the fetus - he replied "we don't have any good data about the possibilities of damage" and likened it to the fact you still pump gas but hydrocarbons also can cause cancer.

Apparently there's a group out of the US which has demonstrated some chromosomal abnormalities (5 and 11 if im not mistaken), but the effect of which has not yet been discovered.

NIOSH has guidelines on how to handle and make chemo. Attached to those guidelines are references that may help your cause. I do not understand the lack of regard that places have for exposure. Why wait 20 - 30 years for some of your staff to develop cancer instead of catching it a lot sooner? Urine screening will show recent metabolites being cleared. The CBC monitoring program is defective in my opinion. CBCs will catch the problem when it is already too late, so other then actually monitoring for active disease it gives you 0 idea as to how effective you are currently able to control for this growing problem.

I've started to dive into this matter a bit further. It is rather surprising some of the data out there on stuff like residual chemo non-disposable surfaces such as countertops after cleaning and the efficacy in minimizing exposures with chemo pins. I am personally looking for the presence of metabolites in urine in those using vertical flow hoods. I am convinced that while they are better then laminar flow, they are not as invincible as people may think.

I think that this is an issue that kind of gets dusted under the carpet but yet everyone knows it exists.

rxlea · Jul 26, 2010

Chemo pins are a must. Some vials have a tiny bit of positive pressure (bortezomib comes to mind). With some drugs, if you stick them more than once, you'll get some leakage (happens all the time with cisplatin if people don't use the pin). I always get pissed if I see another tech do that because it drips all over the damn place and then they touch the chemo bag that someone has to deliver. Truth is, if you were to test me, I've probably got some metabolites. If they tested the area around the hood, there would definitely be residues. I wouldn't be surprised if that's where people get the most exposure these days (especially inventory folks that handle the boxes).

Quiksilver · Jul 27, 2010

rxlea said:
Chemo pins are a must. Some vials have a tiny bit of positive pressure (bortezomib comes to mind). With some drugs, if you stick them more than once, you'll get some leakage (happens all the time with cisplatin if people don't use the pin). I always get pissed if I see another tech do that because it drips all over the damn place and then they touch the chemo bag that someone has to deliver. Truth is, if you were to test me, I've probably got some metabolites. If they tested the area around the hood, there would definitely be residues. I wouldn't be surprised if that's where people get the most exposure these days (especially inventory folks that handle the boxes).

Daunorubicin is a positive pressure offender. Some vials are too small for pins, like fludarabine and vincristine. Other vials like VP-16 and taxol can't use pins. But there are a few articles show how drug still aerosolizes even with pins.

Another thing i wonder is when you pack that IV bag in the yellow chemo bag, how contaminated is that yellow bag?

I also wonder how well soap and water really get rid of chemo that gets on your hands from handling potentially contaminated products.

Thumper17 · Jul 27, 2010

rxlea said:
Really? Hmm...wonder if it is a regional thing because here in AZ, seems like the techs do most of it.

Pharmacists do almost all of the prep at my hospital (in Illinois). I think they enjoy it because it gives them 5 minutes of peace and quiet🙂

They taught me how to make chemo for cases where they are too busy or short staffed and I have made a few bags but I am by no means an expert. I am not worried about exposure too much, it seems that it is nearly impossible for any of the drug to get on me.

We pretty much make it under the same conditions as your hospital - vertical flow hood, chemo gloves/mask/gown/spill mat, vented pins, etc.

One of the pharmacists "refuses" to make chemo claiming "he want to have kids one day", but I think he is just a prick who thinks things like checking/prepping IV bags, referring to techs as "colleagues", and throwing away his own trash are beneath him.

rxlea · Jul 27, 2010

Quiksilver said:
Daunorubicin is a positive pressure offender. Some vials are too small for pins, like fludarabine and vincristine. Other vials like VP-16 and taxol can't use pins. But there are a few articles show how drug still aerosolizes even with pins.

Another thing i wonder is when you pack that IV bag in the yellow chemo bag, how contaminated is that yellow bag?

I also wonder how well soap and water really get rid of chemo that gets on your hands from handling potentially contaminated products.

Yeah, fludarabine and vincristine are far too tiny. Luckily, most of the time, we use the entire vial for one dose.

And I know the yellow bag is contaminated. I mean, you've got chemo on your gloves and then you pack the IV into the bag. It is probably all over the place!

GreenLiving · Jul 27, 2010

I guess this would be a good place to ask a couple of questions:

1) Reading this board has scared me, to be honest, and I came across another older thread that basically said, if you're in pharmacy, you'll have to handle dangerous drugs -- at least sometimes. How often do you pharmacists handle known carcinogens/mutagens? How about when you're in pharmacy school/labs/rotations? (I understand this is about chemo, in particular, but I'd appreciate input regarding other situations, as well.)

2) Do you have the right to refuse to handle a certain drug, based on safety concerns? (My search has led me only to posts about refusing to dispense Plan B and the like.)

Thanks.

pearljam5a1 · Jul 27, 2010

The hospital I worked at back in Virginia had just adopted the Phaseal system to use with chemotherapy. We also used it a bit in my pharmacy technology lab last year in school. It's basically a needleless system that prevents vapor/liquid from escaping the vials. It's much safer than the old way and protects the nurses as well as pharmacy personnel. Here's a link to how the system works if you're not familiar with it:

http://www.carmelpharmausa.com/instructions

Quiksilver · Jul 28, 2010

GreenLiving said:
I guess this would be a good place to ask a couple of questions:

1) Reading this board has scared me, to be honest, and I came across another older thread that basically said, if you're in pharmacy, you'll have to handle dangerous drugs -- at least sometimes. How often do you pharmacists handle known carcinogens/mutagens? How about when you're in pharmacy school/labs/rotations? (I understand this is about chemo, in particular, but I'd appreciate input regarding other situations, as well.)

2) Do you have the right to refuse to handle a certain drug, based on safety concerns? (My search has led me only to posts about refusing to dispense Plan B and the like.)

Thanks.

1. You will come across drugs even in a CVS that you should probably wear gloves while handling. Obviously nuclear and oncology practices are inherently more dangerous.

2. Not really, are you going to refuse methotrexate tablets to your patient with rheumatoid arthritis? what about the patient on Gleevac or fluorouricil or mercaptopurine? A lot of them come in tablet form. Your patient's won't necessarily be happy that you aren't dispensing their oral chemo.

pearljam5a1 said:
The hospital I worked at back in Virginia had just adopted the Phaseal system to use with chemotherapy. We also used it a bit in my pharmacy technology lab last year in school. It's basically a needleless system that prevents vapor/liquid from escaping the vials. It's much safer than the old way and protects the nurses as well as pharmacy personnel. Here's a link to how the system works if you're not familiar with it:

http://www.carmelpharmausa.com/instructions

The literature I have found so far seems to show that this system is the best way to make chemo. However, due to the stability of the drug and size of containers this is not practical.

Chemo Exposure Article

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