Safe Handling of Hazardous Drugs: ASCO Standards

Oncology stewardship practice in the United States: A Hematology/Oncology Pharmacy Association national survey

INTRODUCTION

The treatment of cancer is associated with high risk for toxicity and high cost. Strategies to enhance the value, quality, and safety of cancer care are often managed independently of one another. Oncology stewardship is a potential framework to unify these efforts and enhance outcomes. This landscape survey establishes baseline information on oncology stewardship in the United States.

METHODS

The Hematology/Oncology Pharmacy Association (HOPA) distributed a 38-item survey composed of demographic, institutional, clinical decision-making, support staff, metrics, and technology sections to 675 HOPA members between 9 September 2022 and 9 October 2022.

RESULTS

Most organizations (78%) have adopted general pharmacy stewardship practices; however, only 31% reported having established a formalized oncology stewardship team. More than 70% of respondents reported implementation of biosimilars, formulary management, and dose rounding as oncology stewardship initiatives in both inpatient and outpatient settings. Frequently cited barriers to oncology stewardship included lack of clinical pharmacist availability (74%), lack of oncology stewardship training (62%), lack of physician/provider buy-in (32%), and lack of cost-saving metrics (33%). Only 6.6% of survey respondents reported their organization had defined "value in oncology." Lack of a formalized stewardship program was most often cited (77%) as the rationale for not defining value.

CONCLUSIONS

Less than one-third of respondents have established oncology stewardship programs; however, most are providing oncology stewardship practices. This manuscript serves as a call to action for stakeholders to work together to formalize oncology stewardship programs that optimize value, quality, and safety for patients with cancer.

Antineoplastic Therapy Administration Safety Standards for Adult and Pediatric Oncology: ASCO-ONS Standards

PURPOSE

To update the ASCO-Oncology Nursing Society (ONS) standards for antineoplastic therapy administration safety in adult and pediatric oncology and highlight current standards for antineoplastic therapy for adult and pediatric populations with various routes of administration and location.

METHODS

ASCO and ONS convened a multidisciplinary Expert Panel with representation of multiple organizations to conduct literature reviews and add to the standards as needed. The evidence base was combined with the opinion of the ASCO-ONS Expert Panel to develop antineoplastic safety standards and guidance. Public comments were solicited and considered in preparation of the final manuscript.

RESULTS

The standards presented here include clarification and expansion of existing standards to include home administration and other changes in processes of ordering, preparing, and administering antineoplastic therapy; the advent of immune effector cellular therapy; the importance of social determinants of health; fertility preservation; and pregnancy avoidance. In addition, the standards have added a fourth verification.

STANDARDS

Standards are provided for which health care organizations and those involved in all aspects of patient care can safely deliver antineoplastic therapy, increase the quality of care, and reduce medical errors.Additional information is available at www.asco.org/standards and www.ons.org/onf.

Quality assurance standards and their use in the preparation of parenteral systemic anticancer therapy products in healthcare establishments: a scoping review

OBJECTIVES

The use of parenteral systemic anticancer therapy (SACT) has led to improved cancer survival. A quality assurance (QA) system of the aseptic compounding process is necessary to ensure safe and consistent production of parenteral SACT. This scoping review identifies international evidence and practice relating to QA standards in the preparation of parenteral SACT in healthcare establishments.

METHODS

Standards relating to aseptic compounding in hospital pharmacies and literature exploring the aseptic compounding of parenteral SACT were included. Literature relating to the non-aseptic compounding of medicines and records specific to sterile manufacturing in industrial settings were excluded. A search of several electronic databases, trial registries, the grey literature and websites of key European hospital pharmacy groups and accreditation bodies was conducted on 16 March 2022. A narrative discussion was performed by country, and content analysis of articles was conducted.

RESULTS

Thirty-seven records were included. Standards reviewed covered the work environment, the preparation process and the safety of the workers who are potentially exposed to hazardous chemicals. It was a common practice to include frequent audits to ensure adherence to standards. Some standards also recommended external inspections to allow for further learnings. Periodic reviews are encouraged to ensure standards maintain relevance. National standards of the countries reviewed were based on international standards, with minor adaptations for local conditions.

CONCLUSIONS

The main limitation of this review is that it is limited to countries with a high human development index. The review shows that the use of an internationally recognised standard as a basis for national standards is best practice, and will allow for relevance into the future.

Patients' knowledge and awareness of safe handling of oral anticancer agents at Sultan Qaboos University Hospital in Oman

BACKGROUND

Safe handling of oral anticancer agents is of great concern. There is a lack of clear, national guidelines on how patients can safely handle and dispose of unwanted medications. We aimed to evaluate the safe handling, storage, and disposal of oral anticancer drugs among cancer patients and caregivers at home.

METHOD

This cross-sectional survey of adult cancer patients (or their adult caregivers) used a closed-ended questionnaire from May 2019 to March 2020.

RESULTS

A total of 257 patients (50 ± 15 years; range: 18-93 years) were enrolled; however, only 91% (233/257) reported self-administering oral anticancer medications. Caregivers were more likely to administer oral anticancer agents for patients ≥60 years than those <40 years old (63% vs. 8%; P = 0.001). Most patients (52%; 133/257) did not wash their hands after administering the drug; 74% (164/222) of the respondents reported that their medications were kept in a bedroom cabinet, while 18% (40/222) stored their medications in a refrigerator, and 5% (12/222) in a kitchen cabinet. A total of 55% (68/124) of patients returned their excess oral chemotherapy medications to the hospitals; however, 36% (45/124) disposed of their unused oral chemotherapy drugs in a household garbage container.

CONCLUSION

While two-thirds of patients stored their oral anticancer medications properly, more than half used inappropriate handling procedures. Disposal practices were inconsistent and did not adhere to the reported international guidelines.

Practical Recommendations for the Manipulation of Kinase Inhibitor Formulations to Age-Appropriate Dosage Forms

Over 75 kinase inhibitors (KIs) have been approved for the treatment of various cancers. KIs are orally administrated but mostly lack pediatric age-appropriate dosage forms or instructions for dose manipulation. This is highly problematic for clinical practice in pediatric oncology, as flexible oral formulations are essential to individually set dosages and to adjust it to a child's swallowability. Most KIs are poorly soluble, categorized in Biopharmaceutics Classification System (BCS) class II or IV, and improperly manipulating the KI formulation can alter pharmacokinetics and jeopardize KI drug safety and efficacy. Therefore, the goals of this review were to provide practical recommendations for manipulating the formulation of the 15 most frequently used KIs in pediatric oncology (i.e., bosutinib, cabozantinib, cobimetinib, crizotinib, dabrafenib, dasatinib, entrectinib, imatinib, larotrectinib, nilotinib, ponatinib, ruxolitinib, selumetinib, sunitinib and trametinib) based on available literature studies and fundamental drug characteristics and to establish a decision tool that supports decisions regarding formulation manipulation of solid oral dosages of KIs that have been or will be licensed (for adult and/or pediatric cancers) but are not included in this review.

Treatment of Patients With Late-Stage Colorectal Cancer: ASCO Resource-Stratified Guideline

PURPOSE

To provide expert guidance to clinicians and policymakers in resource-constrained settings on the management of patients with late-stage colorectal cancer.

METHODS

ASCO convened a multidisciplinary, multinational Expert Panel that reviewed existing guidelines, conducted a modified ADAPTE process, and used a formal consensus process with additional experts for two rounds of formal ratings.

RESULTS

Existing sets of guidelines from four guideline developers were identified and reviewed; adapted recommendations from five guidelines form the evidence base and provided evidence to inform the formal consensus process, which resulted in agreement of ≥ 75% on all recommendations.

RECOMMENDATIONS

Common elements of symptom management include addressing clinically acute situations. Diagnosis should involve the primary tumor and, in some cases, endoscopy, and staging should involve digital rectal exam and/or imaging, depending on resources available. Most patients receive treatment with chemotherapy, where chemotherapy is available. If, after a period of chemotherapy, patients become candidates for surgical resection with curative intent of both primary tumor and liver or lung metastatic lesions on the basis of evaluation in multidisciplinary tumor boards, the guidelines recommend patients undergo surgery in centers of expertise if possible. On-treatment surveillance includes a combination of taking medical history, performing physical examinations, blood work, and imaging; specifics, including frequency, depend on resource-based setting.

Additional information is available at www.asco.org/resource-stratified-guidelines.

Occupational exposure assessment in professionals who manipulate and administer antineoplastic drugs in a university hospital in Southern Brazil

INTRODUCTION

Our goal was to demonstrate the effects of occupational exposure to antineoplastic drugs on oxidative stress parameters and DNA damage in health professionals who manipulate and administer antineoplastic drugs in a University Hospital in Southern Brazil.

METHODS

The case-control study with a longitudinal design, involved 64 individuals, 29 of them pharmacists, pharmacy technicians and nurses who were occupationally exposed to antineoplastic drugs and 35 professionals who were not exposed. Gene mutations were determined by micronucleus from salivary fluid; DNA damage by comet assay and oxidative stress parameters in whole blood were also evaluated.

RESULTS

All workers exposed to antineoplastic drugs used personal protective equipment (PPE). It was demonstrated that the total nonprotein thiol and thiobarbituric acid reactive substances levels showed interaction between group and time, with higher levels one week after handling/administration of antineoplastic drugs in the exposed group (GEE, p ≤ 0.0001 and p = 0,013, respectively). Additionally, there was a group effect on the activities of the catalase and glutathione peroxidase antioxidant enzymes (GEE, p = 0.027 and p ≤ 0.0001, respectively), and workers occupationally exposed to antineoplastic drugs had higher enzyme activities compared to those not exposed. No genotoxic damage was demonstrated through the evaluated parameters.

CONCLUSIONS

Despite the correct use of PPE, professionals occupationally exposed to antineoplastic drugs were more susceptible to oxidative stress than those not exposed. The evaluation of the studied parameters is especially important for the definition of conducts and practices in the area, always in search of guaranteeing the establishment of a rational policy to protect workers' health.

Surface contamination with nine antineoplastic drugs in 109 canadian centers; 10 years of a monitoring program

INTRODUCTION

Healthcare workers exposure to antineoplastic drugs can lead to adverse health effects. Guidelines promote the safe handling of antineoplastic drugs, but no safe exposure limit was determined. Regular surface sampling contributes to ensuring workers safety.

METHODS

A cross-sectional monitoring is conducted once a year with voluntary Canadian centers, since 2010. Twelve standardized sampling sites were sampled. Samples were analyzed by high performance mass coupled liquid chromatography. The limits of detection (in ng/cm²) were: 0.001 for cyclophosphamide and gemcitabine; 0.3 for docetaxel and ifosfamide; 0.04 for 5-fluorouracil and paclitaxel; 0.003 for irinotecan; 0.002 for methotrexate; 0.01 for vinorelbine.

RESULTS

The surfaces from 109 centers were sampled between 01/01/2020-18/06/2020. Twenty-six centers delayed their participation because of the COVID-19 pandemic. 1217 samples were analyzed. Surfaces were frequently contaminated with cyclophosphamide (34% positive, 75th percentile 0.00165 ng/cm²) and gemcitabine (16% and <0.001 ng/cm²). The armrest of patient treatment chairs (84% to at least one drug), the front grille inside the biological safety cabinet (BSC) (73%) and the floor in front of the BSC (55%) were frequently contaminated. Centers that prepared ≥5000 antineoplastic drugs annually had higher concentration of cyclophosphamide on their surfaces (p < 0.0001). Contamination measured on the surfaces was reduced from 2010 to 2020.

CONCLUSIONS

This large-scale study showed reproducible long term follow up of the contamination of standardized sites of Canadian centers and a reduction in surface contamination from 2010 to 2020. Periodic surface sampling help centers meet their continuous improvements goals to reduce exposure as much as possible. The COVID-19 pandemic had a limited impact on the program.

Environmental Risk Factors: The role of oncology nurses in assessing and reducing the risk for exposure

BACKGROUND

The multifaceted origins of cancer are related to the dynamic interface between the human body and the environment. It is estimated that as many as 60% of cancers arise from environmental exposures.

OBJECTIVES

This article describes potential risks for exposure to radon, arsenic, pesticides, and antineoplastic agents, which can lead to the development of cancer.

METHODS

The authors performed a review of the literature on environmental exposures and their relationship to the development of cancer.

FINDINGS

Environmental factors are abundant in the home, workplace, and environment. Nurses can lead campaigns to educate the public about environmental risk factors and their effects on the development of cancer.

Appendiceal Mucinous Neoplasm: Nurse Education About a Rare and Complex Disease

BACKGROUND

Appendiceal mucinous neoplasms (AMNs) are a rare and complex spectrum of disease involving a mucinous tumor within the appendix, which can range from benign to malignant. If not limited to the appendix, the mucinous tumor can spread diffusely throughout the peritoneum.

OBJECTIVES

Because of the low incidence of AMN, this study describes the diagnosis and treatment process for this disease, which is not well known to most care providers.

METHODS

An extensive analysis of the current literature, including incidence, diagnosis, and surgical treatment, was performed. A review of the pre- and postoperative needs for patients undergoing surgery was also conducted.

FINDINGS

There is minimal information in the nursing literature about AMN and the complexity of surgical management. Nurses play an important role in caring for these patients and their unique needs both before and after surgery.

Patient-Centered Standards for Medically Integrated Dispensing: ASCO/NCODA Standards

PURPOSE

To provide standards for medically integrated dispensing of oral anticancer drugs and supportive care medications.

METHODS

An Expert Panel was formed, and a systematic review of the literature on patient-centered best practices for the delivery of oral anticancer and supportive care drugs was performed to April 2019 using PubMed and Google Scholar. Available patient-centered standards, including one previously developed by the National Community Oncology Dispensing Association (NCODA), were considered for endorsement. Public comments were solicited and considered in preparation of the final manuscript.

RESULTS

A high-quality systematic review that was current to May 2016 was adopted into the evidence base. Five additional primary studies of multifaceted interventions met the inclusion criteria. These studies generally included a multicomponent intervention, often led by an oncology pharmacist, and also included patient education and regular follow-up and monitoring. These interventions resulted in significant improvements to patient quality and safety and demonstrated improvements in adherence and other patient outcomes.

CONCLUSION

The findings of the systematic review were consistent with the NCODA patient-centered standards for patient relationships and education, adherence, safety, collection of data, documentation, and other areas. NCODA standards were adopted and used as basis for these American Society of Clinical Oncology/NCODA standards. Additional information is available at www.asco.org/mid-standards .

An Approach to Hazardous Medication Surveillance

: Many health care organizations are making changes to their hazardous medication surveillance program (HMSP) in response to United States Pharmacopeia (USP) <800> standards. Absence of best practices for HMSPs and limitations on the ability of such programs to correlate health effects identified on surveillance with workplace exposures historically have left health care institutions to determine if and how to design an HMSP for their workforce. Within this article one approach to the design of an HMSP is discussed and resources such as a health questionnaire and declination form are included that could be modified or adopted by other health care organizations. This information is intended to generate further discussion and collaboration among leaders of employee occupational health services on a national level to address the benefits and challenges of HMSPs.