Urine mutagenicity, chromosomal abnormalities and sister chromatid exchanges in lymphocytes of nurses handling cytostatic drugs

Surface contamination of counting tools after mock dispensing of cyclophosphamide in a simulated outpatient pharmacy

PURPOSE

The primary aim was to determine if dispensing of cyclophosphamide tablets resulted in accumulated residue on pharmacy counting tools during a simulated outpatient dispensing process. Secondary objectives included determining if cyclophosphamide contamination exceeded a defined threshold level of 1 ng/cm² and if a larger number of prescriptions dispensed resulted in increased contamination.

METHODS

Mock prescriptions of 40 cyclophosphamide 50 mg tablets were counted on clean trays in three scenarios using a simulated outpatient pharmacy after assaying five cleaned trays as controls. The three scenarios consisted of five simulated dispensings of one, three, or six prescriptions dispensed per scenario. Wipe samples of trays and spatulas were collected and assayed for all trays, including the five clean trays used as controls. Contamination was defined as an assayed cyclophosphamide level at or above 0.001 ng/cm² and levels above 1 ng/cm² were considered sufficient to cause risk of human uptake. Mean contamination for each scenario was calculated and compared using one-way analysis of variance. P-values of < 0.05 implied significance.

RESULTS

Mean cyclophosphamide contamination on trays used to count one, three, and six cyclophosphamide prescriptions was 0.51 ± 0.10 (p=0.0003), 1.02 ± 0.10 (p < 0.0001), and 1.82 ± 0.10 ng/cm² (p < 0.0001), respectively. Control trays did not show detectable cyclophosphamide contamination. Increasing the number of prescriptions dispensed from 1 to 3, 1 to 6, and 3 to 6 counts increased contamination by 0.51 ± 0.15 (p = 0.0140), 1.31 + 0.15 (p < 0.0001), and 0.80 ± 0.15 ng/cm² (p = 0.0004), respectively.

CONCLUSION

Dispensing one or more prescriptions of 40 cyclophosphamide 50 mg tablets contaminates pharmacy counting tools, and an increased number of prescriptions dispensed correlates with increased level of contamination. Counting out three or more prescriptions leads to trays having contamination that surpasses the threshold at which worker exposure may be increased. Pharmacies should consider devoting a separate tray to cyclophosphamide tablets, as cross-contamination could occur with other drugs and the efficacy of decontamination methods is unclear. Employee exposure could be minimized with the use of personal protective equipment, environmental controls, and cleaning trays between uses. Future investigation should assess the extent of drug powder dispersion, the effects of various cleaning methods, and the potential extent of contamination with different oral cytotoxic drugs.

Assessment of chromosomal aberrations, micronuclei and proliferation rate index in peripheral lymphocytes from Tunisian nurses handling cytotoxic drugs

Anti-neoplastic agents are widely used in the treatment of cancer and some non-neoplastic diseases. These drugs have been proved to be mutagens, carcinogens and teratogens. To check the eventual effects of anti-cancer drugs on occupationally exposed Tunisian nurses, we used chromosomal aberration assay and micronucleus assay. Both parameters have been used to evaluate cellular DNA damage in the biological monitoring of occupationally exposed workers and each assay has its own aim .We used the proliferation rate index to evaluate the cytotoxic effect of antineoplastic drugs in exposed nurses. The frequency of binucleated micronucleated cells was significantly higher in nurses handling cytostatic drugs than in control. We detected also a significant increase of structural chromosomal aberrations. Control subjects generally had significantly higher values of proliferation rate index compared to expose ones. Our results confirm the genotoxic and the cytotoxic effects of antineoplastic drugs in blood lymphocytes circulation. This study points to the necessity to work under more safe and controlled conditions during the preparation and the administration of anti-cancer drugs.

Antineoplastic Drugs as a Potential Risk Factor in Occupational Settings: Mechanisms of Action at the Cell Level, Genotoxic Effects, and Their Detection Using Different Biomarkers

U članku je prikazana osnovna podjela antineoplastičnih lijekova prema mehanizmima djelovanja na razini stanice. Objašnjeni su mehanizmi genotoksičnosti najvažnijih vrsta lijekova koji se primjenjuju u okviru uobičajenih protokola za liječenje zloćudnih novotvorina. Navedena je važeća klasifikacija antineoplastika prema kancerogenom potencijalu, podaci o mutagenom potencijalu te je prikazana njihova podjela u skladu s anatomsko-terapijsko-kemijskim sustavom klasifikacije. Sustavno su prikazani najvažniji rezultati svjetskih i hrvatskih istraživanja na populacijama radnika izloženih antineoplasticima, provedenih u razdoblju 1980.-2009. s pomoću četiri najčešće primjenjivane metode: analize izmjena sestrinskih kromatida, analize kromosomskih aberacija, mikronukleus-testa i komet-testa. Objašnjena su osnovna načela navedenih metoda te raspravljene njihove prednosti i nedostaci. Biološki pokazatelji daju važne podatke o individualnoj osjetljivosti profesionalno izloženih ispitanika koji mogu poslužiti unaprjeđenju postojećih uvjeta rada i upravljanju rizicima pri izloženosti genotoksičnim agensima. Na osnovi prednosti i nedostataka citogenetičkih metoda zaključeno je da je mikronukleus-test, koji podjednako uspješno dokazuje klastogene i aneugene učinke, jedna od najboljih metoda dostupnih za otkrivanje štetnih djelovanja antineoplastičnih lijekova koji su u aktivnoj primjeni.

Reducing workplace cytotoxic surface contamination using a closed-system drug transfer device

BACKGROUND

The potential for staff exposure to antineoplastic agents exists in the workplace despite current recommended safe handling procedures. Reliance on cytotoxic drug safety cabinets (CDSC) to provide total protection from exposure to hazardous drugs is insufficient. Preventing workplace contamination is the best strategy to minimise exposure. PhaSeal is a commercially available system for ensuring the leak-free transfer of hazardous drugs, fitting both the NIOSH and ISOPP definitions of a closed system. To date, there have been no published studies examining the use of a closed system drug transfer device (PhaSeal) under Australian conditions.The purpose of this study is to determine the impact of a closed system drug transfer device on cytotoxic surface contamination in the cytotoxic preparation areas of two Australian metropolitan public hospitals.

METHOD

This was a pre- and post-intervention study in which chemical contamination was tested at baseline then at five and 12 months after the introduction of the a closed system drug transfer device. Cyclophosphamide was used as a surrogate marker for all cytotoxic drugs. Surface wipe sampling was performed at specified sites within the cytotoxic suite using a standardized technique. Commercial products of cyclophosphamide were also sampled.

RESULTS

After five months, contamination was reduced in 13 of the 22 sites sampled (59%), with four of these samples showing undetectable levels of contamination. Two other site samples (9%) remained unchanged. The total contamination of surfaces tested was reduced by 24%. After five months hospital 1 withdrew from the study. After 12 months, surface contamination was reduced in 75% of sample sites. The total contamination of surfaces tested was reduced by 68%. The wipes of the external surface of commercial products detected cyclophosphamide contamination.

CONCLUSION

When used inside a CDSC, the closed system drug transfer device PhaSeal further reduces surface contamination, in some instances to undetectable levels.

The genotoxic risk in health care workers occupationally exposed to cytotoxic drugs--a comprehensive evaluation by the SCE assay

Present study aimed at an integral assessment of sister chromatid exchange (SCE) frequencies in the health care workers occupationally exposed to cytostatics. The results of 500 individual analyses were evaluated. Drug handling practice was investigated in parallel and the results showed that cytostatics are mostly prepared outside hospital pharmacy (98%) and mainly handled by nurses (96%). Mean frequency of SCE was 5.63 +/- 2.28, while HFC represented 9.65% of the cells analysed. Both values were higher compared to previously established control values for Croatian population. The duration of exposure, profession, age, gender, smoking habit, medical exposures, and simultaneous exposure to other occupational mutagens significantly contributed to SCE and HFC values. The usefulness both biomarkers in the assessment of cytogenetic damage is confirmed. Since current practice in Croatian hospitals does not include regular monitoring of workplaces, to ensure maximal occupational safety, a surveillance on exposed health care workers, including periodic biomonitoring, is recommended.

Closed hyperthermic intraperitoneal chemotherapy with open abdomen: a novel technique to reduce exposure of the surgical team to chemotherapy drugs

BACKGROUND

Exposure of the surgical team to toxic drugs during hyperthermic intraperitoneal chemotherapy (HIPEC) remains a matter of great concern. During closed-abdomen HIPEC, operating room staff are not exposed to drugs, but the distribution of the heated liquid within the abdomen is not optimal. With open-abdomen HIPEC, the opposite is true. Although the open-abdomen method is potentially more effective, it has not become a standard procedure because of the risk of exposure of members of the team to drugs.

METHODS

We present a new technique (closed HIPEC with open abdomen) which ensures protection against potentially contaminating exposure to liquids, vapours and aerosols, and allows permanent access to the whole abdominal cavity. Its principle is to extend the abdominal surgical wound upwards with a sort of "glove-box". The cutaneous edges of the laparotomy are stapled to a latex "wall expander". The expander is draped over a special L-section metal frame placed above the abdomen. A transparent cover containing a "hand-access" port, like those used in laparoscopic surgery, is fixed inside the frame.

RESULTS

In 10 patients, this device proved to be hermetic for both liquids and vapours. Intra-abdominal temperature was maintained between 42 and 43 degrees C during most of the procedure. The whole abdominal cavity was accessible to the surgeon, allowing optimal exposure of all peritoneal surfaces.

CONCLUSION

This technique allows optimal HIPEC, while limiting the potential toxic effects for the surgical, medical and paramedical teams.

Platinum group elements in the environment and their health risk

Accumulation of platinum group elements (PGEs) in the environment has been increased over the time. Catalytic converters of modern vehicles are considered to be the main sources of PGE pollution, since the correlation is between the Pt:Rh ratios in various environmental compartments and in converter units. The present literature survey shows that the concentration of these metals has increased significantly in the last decades in diverse environmental matrices; like airborne particulate matter, soil, roadside dust and vegetation, river, coastal and oceanic environment. Generally, PGEs are referred to behave in an inert manner and to be immobile. However, there is an evidence of spread and bioaccumulation of these elements in the environment. Platinum content of road dusts can be soluble, consequently, it enters the waters, sediments, soil and finally, the food chain. The effect of chronic occupational exposure to Pt compounds is well-documented, and certain Pt species are known to exhibit allergenic potential. However, the toxicity of biologically available anthropogenic Pt is not clear. Hence, there is a need to study the effect on human health of long-term chronic exposure to low levels of Pt compounds.

Biological and environmental monitoring of hospital personnel exposed to antineoplastic agents: a review of analytical methods

In order to assess occupational exposure of hospital personnel involved in the preparation and administration of antineoplastic drugs, biological and environmental monitoring are essential to identify the main exposure routes and to quantify potential health risks. If workplace contamination cannot be completely avoided, it is of utmost importance to reduce exposure to the lowest possible levels. To this aim, not only do education and training of the exposed subjects play an important role, but accurate standardized sampling techniques and analytical methods are also required. A critical overview of the most significant methods available in the literature is presented and their value is discussed, especially with respect to their sensitivity and specificity. In addition, attention is given to validation procedures and, consequently, to their reliability. The results from the most important surveys carried out at hospital departments are also discussed, with a view to improving both monitoring strategies and moreover working conditions.

Monitoring of DNA damage in foundry and pottery workers exposed to silica by the alkaline comet assay

BACKGROUND

Workers in foundry and pottery are exposed to a mixture of chemicals and silica, which is suspected to cause genetic alterations.

METHODS

To investigate the potential hazard associated with the occupational exposure to silica, DNA damage in the peripheral lymphocytes of 30 foundry and 22 pottery workers were examined by the alkaline single-cell gel electrophoresis or Comet Assay, and compared to 52 healthy subjects with no history of occupational silica or chemical exposure.

RESULTS

The DNA damage observed in the lymphocytes of both foundry and pottery workers was significantly higher than that in their controls. Cigarette smoking was also related to DNA damage since the DNA damage observed in smoking silica-exposed workers compared with the non-smoking workers was significantly higher.

CONCLUSIONS

Occupational exposure of silica from foundry and pottery workplaces has been associated with the increased DNA damage and smoking which represents an additional risk factor and must be avoided.

Follow-up genotoxicological monitoring of nurses handling antineoplastic drugs

Most of the antineoplastic drugs used in the treatment of tumors are carcinogenic to humans. Hospital nurses are often subject to possible occupational carcinogen exposure. Exposure may occur during handling and administration of infusion solutions containing cytostatics. A genotoxicological monitoring system to detect genotoxic changes was developed in our laboratory, helping to improve working conditions and subserving primary prevention. Multiple-endpoint follow-up genotoxicological monitoring was performed in peripheral blood lymphocytes (PBLs) among 4 groups of 95 nurses (152 investigations) occupationally exposed to cytostatics. The results were compared to those of historical and industrial controls. The genotoxicological endpoints were the determination of the frequency of sister chromatid exchanges (SCEs) and the cells with high-frequency SCEs (HFC), the frequency of structural and numerical chromosome aberrations. and the measurement of ultraviolet-light-induced unscheduled DNA-repair synthesis (UDS). In Hospital 1, where nurses worked without a safety cabinet, the percentage of cells with chromosome aberrations (AC) was significantly higher than that of the controls. In Hospital 2, where nurses used inadequate safety cabinets (with horizontal airflow), significantly elevated levels of AC, SCE, HFC, and UDS were detected. During follow-up, in Hospital 2 at the time of the second investigation AC was still significantly higher, although safety conditions had been improved. The results indicate the presence of genotoxic damage in hospital nurses working with no or inadequate safety equipment. In Hospitals 3 and 4 where nurses using biological safety cabinets, the results were lower than those in the previous two groups. In Hospital 3 in the first year of the study AC was as at the level of industrial controls. During follow-up in the course of the repeated investigations a fluctuation in AC above the control level and an increase in HFC in yr 4 and 6 of the study were observed. In this group, the fluctuation in AC and HFC during the study points to the possibility of genotoxic exposure with cytostatics despite of the use of suitable safety cabinets, drawing attention to other possible routes of exposure. In Hospital 4, both AC and HFC were elevated. These data corroborate the need to maintain safety measures to avoid exposure, and the necessity of intervention in the case of exposure when using and handling hazardous carcinogenic agents. The results also indicate a certain expression time for genotoxic changes, which can lead to late somatic mutations as well as to a possible higher risk of cancer.

Use of the alkaline comet assay to monitor DNA damage in technicians exposed to low-dose radiation

The exposure of human beings to ionizing radiation is still of great concern in occupational and environmental medicine, and the widespread use of radiotherapy in the treatment of cancer has led to anxiety about the possible hazards to staff who are at risk of such occupational exposure. In this study, DNA damage in the peripheral lymphocytes of 30 technicians employed in radiation oncology departments for at least 1 year were examined by the alkaline single-cell gel electrophoresis "comet" technique. The results were compared with those of 30 controls with comparable age, sex, and smoking habits who were not working in radiation oncology or chemotherapy services. The DNA damage observed in the lymphocytes of the technicians was significantly higher than that in the controls (P < 0.001). Cigarette smoking was also related to increases in DNA damage, and a significant association was found between the duration of occupational exposure to low-dose ionizing radiation and the DNA damage.

Assessment of DNA damage in nurses handling antineoplastic drugs by the alkaline COMET assay

The widespread use of chemotherapy in the treatment of cancer has led to anxiety about the possible hazards to staff involved in the preparation and administration of cytotoxic agents. Careless handling of antineoplastic drugs may lead to exposure in detectable amounts by means of chemical or biological methods in the body fluids or cell samples but the information about the mutagenic effects of these agents on nurses is limited and inconsistent. DNA damage in peripheral lymphocytes of 30 professional nurses employed in the oncology departments for at least 6 months were examined by the alkaline single cell gel electrophoresis, 'COMET' technique. The results were compared to that of 30 controls with comparable age, sex and smoking habits, not practising in the chemotherapy services. Work characteristics of the exposed nurses and the use of personal protective equipment were also investigated. The DNA damage observed in the lymphocytes of the nurses was significantly higher than the controls (p<0.001). The observed DNA damage was found to be significantly lower (p<0.001) in nurses applying the necessary individual safety protections during their work. Cigarette smoking was not related to increases in DNA damage, also a significant association was not found between the duration of occupational exposure to antineoplastic drugs and the DNA damage.

Nurses' and pharmacists' exposure to antineoplastic drugs: findings from industrial hygiene scans and urine mutagenicity tests

Data from 83 nurses and pharmacists handling antineoplastic drugs and 35 nurse/pharmacist controls who participated in a national study of antineoplastic drug-handling risks were examined to investigate antineoplastic drug exposure. Measures of external exposure included self-completion drug logs and industrial hygiene scans conducted in clinical settings. Internal exposure was measured by urine mutagenicity tests on end-of-week 24-hour urine specimens. To control for potential confounders, the staff was asked to complete food and hobby diaries and to avoid identified mutagenic substances for 1 week before collection of 24-hour urine samples. On the scans of the drug handlers, 13% showed one or more spots of drug contamination on gloved and ungloved hands, gowns, or shoes. Of the 24-hour urine samples, 15% were mutagenic for Salmonella typhimurium: Rates did not differ significantly for drug handlers and controls. Among nurses who both prepared and administered antineoplastics, those with positive mutagenicity tests handled more doses of the drugs, used less skin protection, and had more skin contact with the drugs than those with negative tests. Nurses who only administered the drugs and had positive mutagenicity tests handled fewer doses of drugs than those with negative tests, but they also reported less use of protection and more skin contact. For both groups of nurses, skin contact with antineoplastics was associated with positive mutagenicity test results (p < 0.01).

Biomonitoring of occupational exposures to cytostatic anticancer drugs

Cytostatic anticancer drugs are known as carcinogenic, mutagenic, and teratogenic risk factors for health care workers who are occupationally exposed during the preparation and administration of such drugs. During the last 20 years, several researchers have developed and validated methods to monitor occupational exposure to such agents. This paper reviews the literature with respect to the possible effects on occupationally exposed hospital workers and establishing occupational exposure.

DNA damage in nurses handling antineoplastic agents

In 91 nurses from several divisions of four hospitals in Germany the genotoxic effect caused by the occupational exposure presumably due to mixing of antineoplastic agents was investigated. The amount of DNA single strand breaks and alkali labile sites in the peripheral mononuclear blood cells of the nurses was measured using the alkaline elution method. In ten nurses handling antineoplastic agents not using recommended safety precautions such as safety hoods, gloves or surgical masks a 50% higher level of DNA strand breaks and alkali-labile sites (p < 0.005; U-test) was detected compared to 54 controls. After applying recommended safety precautions a statistically significant decrease (p < 0.01) in the level of DNA strand breaks to the level of controls was observed. In other nurses handling antineoplastic agents by using adequate safety equipment no significantly different amount of DNA strand breaks compared to that of controls was detected. No significant correlation between the level of DNA strand breaks and the weekly contact frequency, the life-time exposure to antineoplastic agents, or the time elapsed since the last handling of the drugs was found in this study.

Urinary cyclophosphamide excretion and chromosomal aberrations in peripheral blood lymphocytes after occupational exposure to antineoplastic agents

In this study we have compared the results of a method for the detection of cyclophosphamide in urine and the results of analysis of chromosomal aberrations in peripheral blood lymphocytes of four groups of subjects with various exposure statuses. These groups are 17 Dutch and 11 Czech exposed workers (mainly hospital nurses and pharmacy technicians) handling antineoplastic agents and 35 Dutch and 23 Czech controls (nurses, medical doctors, pharmacy and lab technicians) not handling these drugs. The groups were subdivided into smokers and non-smokers because of a confounding effect of smoking. Within the Dutch groups, the percentage of aberrant cells and the number of breaks per cell were increased for smokers compared to non-smokers. The percentage of aberrant cells was increased in Dutch exposed workers in comparison with Dutch control workers. Within the Czech groups the percentage of aberrant cells and the number of breaks per cell were increased in exposed workers in comparison with control workers. However, both Dutch and Czech smokers mainly contributed to the increase. The results suggest an additive effect of exposure and smoking in the Dutch subjects and a more than additive effect in the Czech subjects. In urine samples of three out of 11 Dutch exposed workers cyclophosphamide was found in a range of 0.1-0.5 micrograms/24 h. Higher levels were detected in the urine of eight out of 11 Czech exposed workers, a range of 0.1-2.9 micrograms/24 h. No correlation was observed between the amounts of cyclophosphamide excreted in urine on the one hand and the percentage of aberrant cells and the number of breaks per cell on the other hand. The present study is the first study showing that hospital workers having an increase in chromosome aberrations related to their work are exposed to at least one antineoplastic agent.

Biomonitoring of nurses handling antineoplastic drugs

The micronuclei analysis in exfoliated cells of the buccal cavity was employed in the cytogenetic monitoring of nurses handling antineoplastic drugs. The group under study consisted of 25 subjects who showed a marked increase in micronucleated cells as compared with the control group (Chi-square = 15.12, with one degree of freedom, P < 0.001).

Chromosomal aberrations in peripheral lymphocytes of nurses and physicians handling antineoplastic drugs

The frequencies of structural chromosome aberrations of persons occupationally exposed to antineoplastic drugs without adequate protection were measured in peripheral blood lymphocytes of 106 persons from five oncological units and in an adequate control population. The observed chromosomal aberration frequencies were 3.3 +/- 0.1 aberrations per 100 cells in the exposed group and 0.6 +/- 0.1 aberrations per 100 cells in the controls. Chromosomal aberration frequencies were not correlated with age, duration of exposure and smoking habits. The results stress the necessity to protect hospital staff against the potential risk related to the handling of antineoplastic drugs.

Increasing rates of DNA single-strand breaks in lymphocytes of clinical personnel handling cytostatic drugs

A total of 27 persons, working in cancer stations with exposure to cytostatics, and 40 healthy control persons were examined for DNA single-strand breaks in peripheral lymphocytes. Non-smoking personnel from cancer stations were found to have an increased rate of DNA single-strand breaks compared to the non-smoking control subjects. In the case of smokers an increased rate of DNA single-strand breaks could be recorded for those working in cancer stations as well as with the controls. DNA single-strand breaks indicate reversible damage to DNA. As DNA repair is not perfect in every case, an increased number of DNA single-strand breaks leads to irreversible DNA damage.

Environmental effects on chromosomes in oncology and radiology department personnel

Long-term, low levels of antineoplastic drugs and ionizing radiation in the work environment may have genotoxic effects on chromosomes in personnel. The effects of ionizing radiation is acknowledged in occupational medicine and therefore various measures have been undertaken to prevent such effects. However, there are no protective measures for workers exposed to antineoplastic drugs. In this study metaphase chromosome preparations were analyzed in 126 nurses and radiology technicians. They were divided into three equal groups. The first group consisted of shift nurses in an oncology department handling antineoplastic drugs. The second group consisted of radiology technicians in a radiology department and the third group acted as controls. Structural chromosomal aberrations were increased among those nurses exposed to antineoplastic drugs in comparison with technicians (P less than 0.05) and controls (P less than 0.01), respectively.

Baseline and phosphoramide mustard-induced sister-chromatid exchanges in pharmacists handling anti-cancer drugs

Determinations of baseline and mutagen-induced sister-chromatid exchanges (SCE) have been used as indicators of previous mutagen exposure in several human populations. Mutagen-induced SCE is based on the premise that a genetic outcome may depend not only on a present exposure, but also on a cell's "memory" of previous exposure. The genotoxicity of some anti-cancer drugs including cyclophosphamide (CP) has been studied by determining baseline and mutagen-induced SCE in peripheral blood lymphocytes in treated cancer patients. This study examined the in vivo genotoxic effects of occupational exposure to anti-cancer drug handling by relating baseline and phosphoramide mustard (PM) -induced SCE levels with duration of anti-cancer drug handling as a surrogate for anti-cancer drug exposure dose. The mean baseline SCE for the population was 5.19 +/- 0.17 and was not correlated with duration of drug handling. However, a strong correlation was demonstrated between inducible SCE values and life-time duration of drug handling with r = 0.63 (p less than 0.0001 for low-dose PM challenge (0.1 mg/ml PM) and r = 0.67 (p less than 0.0001) for high-dose PM challenge (0.25 mg/ml PM). A similar relationship was seen for PM-induced SCE and duration of anti-cancer drug handling for the workers' present job with correlations obtained being r = 0.63 (p less than 0.0001) for low-dose PM and r = 0.59 (p less than 0.0001) for high dose PM. The short-lived nature of the baseline SCE lesion is discussed as a limitation in population surveillance studies, as it reflects primarily recent mutagen exposure and persists only for days to weeks after exposure. The induced SCE measure is postulated to provide an integrating dosimeter of remote previous exposure, improving upon the current limitation of the baseline SCE measure and allowing the "unmasking" of previous exposure in a provocative framework.

Detection of contamination with antineoplastic agents in a hospital pharmacy department

The contamination with fluorouracil, cyclophosphamide and methotrexate was studied in a hospital pharmacy department where these drugs were prepared. In the preparation room, air samples were taken before and during preparation of the drugs. Methotrexate was detected in one sample which was collected during preparation (0.3 micrograms/m3). Spot samples were taken in the vertical laminar airflow safety hood before and after preparation of the drugs and after cleaning of the hood. Contamination of the laminar airflow hood was: cyclophosphamide: 1-160 ng/cm2; fluorouracil: 10-62 ng/cm2 and methotrexate: 2-633 ng/cm2. Spot samples from the floor in front of and beneath the laminar airflow hood showed contamination with especially fluorouracil (48-236 micrograms/m2). The gloves used during preparation of the drugs were contaminated mainly with fluorouracil (5-980 ng/cm2). Urine samples from two workers involved in the preparation of the drugs were analysed for unmetabolized cyclophosphamide; it was not detected. Although no uptake of cyclophosphamide was established, it is shown that the methods for measurement of cyclophosphamide, fluorouracil and methotrexate in the preparation room are applicable for the control of occupational exposure to these drugs.

Sister chromatid exchanges and chromosome aberrations in lymphocytes of nurses handling antineoplastic drugs

Chromosomal aberrations (CA) and sister-chromatid exchanges (SCE) were investigated in peripheral lymphocytes of 15 nurses and nurse's aides handling cytostatic agents in hospital oncology units. Significantly increased frequencies were noted for both CA and SCE rates when the exposed individuals were compared with 15 nurses working in other hospital units and to a control sample matched by sex and age. This points to the need for emphasizing protective measures in the handling of anti-neoplastic agents.

Urinary cyclophosphamide excretion in rats after intratracheal, dermal, oral and intravenous administration of cyclophosphamide

The urinary excretion of unmetabolized cyclophosphamide was studied in rats after intratracheal, dermal, oral and intravenous administration. Rats were given two doses of 1 mg kg-1 cyclophosphamide 48 h apart and urine was collected for 96 h after the first treatment. With the help of a phosphor-specific filter in a flame photometer attached to a gas chromatograph, low levels of cyclophosphamide were determined after derivatization with trifluoroacetic anhydride. Cumulative excretion as a percentage of dose ranged from 4.0 to 6.9 after the first dose and 2.7 to 5.5 after the second dose. The highest rate of excretion after the second administration was observed in rats treated intratracheally, while cumulative excretion was higher (6.9%) after the first than after the second (2.7%) intravenous treatment. The most prolonged excretion was observed after dermal application.

Sister chromatid exchanges in lymphocytes of nurses handling antineoplastic drugs

The effects of handling antineoplastic drugs were examined in a group of 23 nurses working in the hematology and oncology departments of different university hospitals in Ankara and in a group of 50 unexposed controls. The cytogenetic repercussions of exposure were assessed by examining sister chromatid exchanges (SCEs) in circulating lymphocytes which result from the breakage and rejoining of DNA at apparently homologous sites on the 2 chromatids of a single chromosome. A significant increased frequency of SCE is observed in nurses in daily contact with antineoplastics (n = 23, mean SCEs/cell +/- SE 6.5 +/- 0.2) as compared to a group of controls (n = 50, mean SCEs/cell 5.2 +/- 0.2). The nurses who smoked also had a higher SCE frequency (n = 15, mean SCEs/cell 7.0 +/- 0.3) than non-smokers, (n = 8, mean SCEs/cell 5.5 +/- 0.3). A significant increase (P less than 0.001) in the mean number of SCE was found for non-smoking nurses as compared to non-smoking controls (n = 27, mean SCEs/cell 4.1 +/- 0.2).

Chromosomal abnormalities among nurses occupationally exposed to antineoplastic drugs

The effect of handling antineoplastic drugs was examined in 42 nurses working in an oncology department, and the same number of nurses not exposed to antineoplastic drugs acted as controls. The exposure effect was evaluated by analysis of sister chromatid exchanges (SCE) incidence and structural chromosomal abnormalities. SCE as well as chromosomal abnormalities in the exposed group were increased (p less than 0.001 and p less than 0.01, respectively). Sign test for paired sample was used for statistical assessment.

The risks of handling cytotoxic drugs. II. Recommendations for working with cytotoxic drugs

Presuming that preparation of antineoplastic drugs without proper protection may lead to mutagenic urine (of which the effects are uncertain), one has to take great care when preparing these drugs. Apart from Norway no other country has national regulations issued by the government for handling cytostatic agents. Many organizations in various countries have made their own guidelines, which may be adapted to the situations in local hospitals. The following recommendations have been compiled after a review of the literature. They reflect a personal set of guidelines for preparation, administration and disposal of cytotoxic drugs. They are probably the minimum precautions that should be taken, and have not been approved by any committee or agency. Further precautions must first have their potential benefit weighed against probable inconvenience and additional costs.

The risks of handling cytotoxic drugs. I. Methods of testing exposure

Results of various biological and physical/chemical tests of the urines or blood of health-care personnel working with cytotoxic drugs are discussed. The outcomes of these tests are conflicting and inconclusive. The physical/chemical tests seem to be an alternative method. However, until now it has not been possible to establish the threshold concentration in urine or blood beneath which no effect has to be expected. Therefore, the interpretation of the concentration of cytotoxic drugs and/or the metabolites in the urine or blood is difficult. As long as one will not be able to provide conclusive data on the health hazards when working with cytotoxic drugs, protective measures have to be taken in order to lower the risk as much as possible.

Chromosome and SCE analysis in peripheral lymphocytes of persons occupationally exposed to cytostatic drugs handled with and without use of safety covers

The frequency of structural chromosome aberrations and sister-chromatid exchanges in peripheral blood lymphocytes of nurses handling cytostatic drugs without a safety cover is compared with that of individuals doing this work exclusively under a safety cover and with that of nurses working under similar conditions but not handling cytostatics. The mean yield of dicentric chromosomes, (4.3 +/- 0.7)/1000 cells, and acentric fragments, (15.4 +/- 1.4)/1000 cells, in the occupationally exposed group is significantly increased in comparison to individuals working with protection (dic: (1.1 +/- 0.4)/1000 cells, ace: (11.2 +/- 1.2)/1000 cells) and nurses not handling cytostatics (dic: (2.1 +/- 0.5)/1000 cells, ace: (9.9 +/- 1.1)/1000 cells). The frequency of chromatid breaks and SCE is not significantly different between these groups (p greater than 0.05).

Effects of in vivo exposure to antineoplastic drugs on DNA repair and replication in human lymphocytes

In peripheral blood lymphocytes of 12 nurses and 3 patients exposed to antineoplastic drugs we determined the ability to repair DNA after UV irradiation and DNA replicative synthesis after stimulation by PHA. In nurses the levels of unscheduled DNA synthesis and DNA replication were not different than in a control group, whereas in patients significant changes were observed during and after chemotherapy in the level of both types of DNA synthesis.

The effect of smoking on the frequencies of asymmetrical and symmetrical chromosome exchanges in human lymphocytes

Cytogenetic analysis was performed on blood lymphocyte cultures from 12 moderate smokers (15-20 cigarettes/day) and 12 non-smokers. An increase in dicentrics was observed in the smokers using block-stained material but this was not significant. Analysis of banded material, enabling both symmetrical and asymmetrical aberrations to be scored, revealed a significant increase in total aberrations thus emphasizing the need to identify all chromosome rearrangements when examining the effects of low-level chronic exposures to clastogens.

Sister chromatid exchanges and chromosomal aberrations in lymphocytes of nurses handling cytostatic agents

A cohort study of 29 nurses who constantly handled cytostatic drugs, and 29 controls matched according to sex and age, was carried out between 1983 and 1986. Cytogenetic damage was assessed by sister chromatid exchanges (SCE) and chromosomal aberrations. No significant increase in mean number of SCE was found for nurses (7.37) as compared to matched controls (7.00), whereas a significant excess of SCE (p less than 0.001) was observed for smokers (8.23) as compared to non-smokers (6.75). The number of SCE was studied in relation to the amount and nature of cytostatics handled as well as to the duration of exposure. A significant association (p less than 0.05) was found between individual mean number of SCE and the total number of drugs handled after adjustment for confounding factors. In contrast, the number of SCE was not significantly related to the nature of drugs handled or to the duration of exposure. With regard to chromosomal damage, no significant difference was observed between nurses and controls in gap, break, dicentric and translocation frequencies.

Bibliography: handling considerations for cancer chemotherapeutic agents

Since the introduction of antineoplastic agents in the 1940s, there have been reports of the effects of these agents on workers who have had prolonged contact with them. The Regional Oncology Drug Information Center (RODIC) at Memorial Sloan-Kettering Cancer Center receives numerous inquiries nationwide regarding our policies and procedures for handling antineoplastic agents. In August 1987, RODIC conducted a computerized literature search on the handling of antineoplastic agents and the risks to hospital employees, coming in contact with these agents. We used the MEDLINE system from 1966 to the present, limiting the search to English-language articles. This article provides a comprehensive bibliography on the handling of antineoplastic agents.

Epidemiology in protection and prevention against environmental mutagens/carcinogens. Examples from occupational medicine

Subjects occupationally exposed to potential mutagens/carcinogens represent the most suitable groups for epidemiological studies aimed at assessing the risk for the individual or the offspring. Several cancer risks to humans have been detected by epidemiological studies performed in occupational settings. Cancer epidemiology studies have been able (a) to identify specific occupations or agents associated with the risk; (b) to verify the results of experimental studies; (c) to test the effectiveness of changes in production or preventive measures in decreasing risks. Reproductive epidemiology has suggested a risk of spontaneous abortions or of malformation in the offspring of workers exposed to some chemicals or occupations, but data are often conflicting due to methodological problems. With the aim of early assessment of risk in mind, the epidemiological use of indicators of exposure or of the early effect of exposure to genotoxic agents is increasingly applied to occupational groups. Cytological monitoring of subjects at risk of occupational cancer of lung or bladder is carried out mainly to diagnose precancerous lesions of target tissues. Cytogenetic methods (chromosome aberrations, SCE, micronuclei) in somatic cells provide a means for detecting early effects of occupational exposure to known or potential mutagens/carcinogens in selected groups of individuals, but their significance is widely debated. Monitoring of urinary mutagenicity, as applied in nurses handling cytostatic drugs, is an example of how an indicator of exposure to genotoxins can be used to evaluate the impact of preventive measures. Among the perspectives, biochemical epidemiology seems to be promising in detecting individuals genetically susceptible to cancer.