1. McDiarmid M, Oliver M et al. Chromosome 5 and 7 abnormalities in oncology personnel handling anticancer drugs. JOEM. 2010; 52: 1028-1034.

Biologically important exposure to genotoxic drugs is apparently occurring in oncology work settings despite reported use of safety practices.   

2. Peelen S, Roeleveld N et al. Toxic effects on reproduction in hospital personnel. Netherlands: Elsevier; 1999. (Translation by Interverbum, Gothenburg Sweden from original Dutch)

The study suggests an increased risk of spontaneous abortion and low birth weight associated with exposure to cytostatic agents.

The results were found particularly in nurses working in outpatient clinics and/or involved in the preparation of cytostatic agents and handling waste.

3. Sessink PJM, Bos RP. Drugs hazardous to healthcare workers (evaluation of methods for monitoring occupational exposure to cytostatic drugs). A Review Article. Drug Safety. 1999; 20(4): 347-359.

This paper reviews the literature concerning possible health risks for individuals occupationally exposed to cytostatic drugs.

In the Netherlands, a limit has been set on the number of new cases of cancer to one extra case per million employees per year. This risk increase should be monitored and risks greater than 100 cases per million employees per year should be not accepted.

The value of new sensitive monitoring methods has been demonstrated by the detection of cyclophosphamide in the urine of healthcare workers who are not directly involved in the preparation and administration of cyclophosphamide, such as pharmacist checks after preparation.

A possible reason for this is suggested to be the inhalation of cytostatics in gas form.

4. Valanis B, Vollmer WM, Steele P. Occupational exposure to antineoplastic agents: self-reported miscarriages and stillbirths among nurses and pharmacists. J Occup Environ Med. 1999; 41(8): 632-638.

The study suggests a statistically significant increase in the risk of miscarriage in women handling cytostatic agents prior to or during pregnancy.

5. Labuhn K, Valanis B, Loveday K et al. Nurses´ and pharmacists´ exposure to antineoplastic drugs: findings from industrial hygiene scans and urine mutagenicity tests. Cancer Nurs. 1998; 21(2): 79-89.

These findings indicate that biological intake (positive urine mutagenicity tests) can occur among healthcare workers who handle cytostatic drugs.

6. Sessink PJM, Kroese ED, van Kranen HJ et al. Cancer risk assessment for healthcare workers occupationally exposed to cyclophosphamide. Int Arch Occup Environ Health. 1995; 67: 317-323.

This study establishes a minimal level of acceptable extra cancer risks per one million. The Netherlands propose that a target of one extra cancer case per million is acceptable and greater than 100 per million is totally unacceptable. Any risk between 1 and 100 should be dealt with aggressively. Increased cancer risks of healthcare staff exposed to cyclophosphamide are theoretically shown to be 17-100 extra cases per million employees, with regard to leukemia in women. Cases of bladder cancer in men and women exposed to CP increased to 15-76 extra cases per million.

7. Hansen J, Olsen JH. Cancer morbidity among Danish female pharmacy technicians. Scand J Work Environ Health. 1994; 20: 22-26.

The study evaluated the increased risk of cancer in 9,499 active and retired female pharmacy staff licensed as of January 1, 1970 or later. The study indicated an increased risk of non-Hodgkin’s lymphoma among the long-term pharmacy staff. In addition, there was a 53% significantly higher risk for non-melanoma skin cancer than amongst the general population.

8. Sessink PJM, Cerna M, Rossner P et al. Urinary cyclophosphamide excretion and chromosomal aberrations in peripheral blood lymphocytes after occupational exposure to antineoplastic agents. Mutat Res. 1994; 309: 193-199.

This study involved a group of Dutch and Czech healthcare workers handling antineoplastic drugs. The study compared the results from a method detecting cyclophosphamide in urine with the results from an analysis of chromosomal aberrations in peripheral blood lymphocytes.

This study shows that hospital workers have an increase in chromosome aberrations if they work with at least one antineoplastic agent.

9. Sauere-Cubizolles MJ, Job-Spira N, Estryn-Behar M. Ectopic pregnancy and occupational exposure to antineoplastic drugs. Lancet. 1993; 341: 1169-1171.

Stucker I, Caillard J-F, Collin R et al. Risk of spontaneous abortion among nurses handling antineoplastic drugs. Scand J Work Environ Health. 1990; 16: 102-107.

Selevan SG, Lindbohm M-L, Hornug RW et al. A study of occupational exposure to antineoplastic drugs and fetal loss in nurses. N Engl J Med. 1985; 313: 1173-1178.

These three studies report higher rates of spontaneous abortion or ectopic pregnancies in women exposed to cytostatic drugs during pregnancy.   

10. Sessink PJM, Scholtes MM, Anzion RBM et al. Determination of cyclophosphamide in urine by gas chromatography-mass spectometry. J Chromatogr B Biomed Appl. 1993; 616: 333-337.

The paper describes the mass spectrometry method of testing urine for traces of cyclophosphamide. The method is deemed appropriate for the routine analysis of urine for antineoplastic agents in healthcare workers.

11. Valanis B, Vollmer W, Glass A. Acute symptoms associated with antineoplastic drug handling among nurses. Cancer Nurs. 1993; 16(4): 288-295.

The findings of this study are that skin contact is the best predictor of acute symptoms in nurses working with chemotherapy. Symptoms shown to increase with skin exposure to chemo or patient excreta (those receiving chemotherapy) included loss of appetite, nausea, vomiting, diarrhea, coughing, shortness of breath, irregular heart beat, increased blood pressure, hair loss, pain during urination, etc.

12. Valanis BG, Vollmer WM, Labuhn KT et al. Association of antineoplastic drug handling with acute adverse effects in pharmacy personnel. Am J Health-System Pharm. 1993; 50: 455-462.

The findings of this study are that skin contact is the best predictor of acute symptoms in nurses working with chemotherapy. Symptoms shown to increase with skin exposure to chemo or patient excreta (those receiving chemotherapy) included loss of appetite, nausea, vomiting, diarrhea, coughing, shortness of breath, irregular heart beat, increased blood pressure, hair loss, pain during urination, etc.

13. Skov T, Maarup B, Olsen J et al. Leukemia and reproductive outcome among nurses handling antineoplastic drugs. Br J Ind Med. 1992; 49: 855-861.

Reports show an increased frequency of leukemia cases in nurses exposed to cytostatic drugs.

14. McDonald AD, McDonald JC, Armstrong B et al. Congenital defects and work in pregnancy. Br J Ind Med. 1988; 45: 581-588.

Hemminki K Kyyronen P, Lindlohm ML. Spontaneous abortions and malformations in the offspring of nurses exposed to anaesthetic gases, cytostatic drugs, and other potential hazards in hospitals, based on registered information of outcome. J Epidemiol Community Health. 1985; 39: 141-147.

These studies report findings of malformations in the offspring of women exposed to cytostatic drugs.

15. Sotaniemi EA, Sutinen S, Arranto AJ et al. Liver damage in nurses handling cytostatic agents. Acta Med Scand. 1983; 214: 181-189.

This study describes liver damage in three oncology nurses hypothesized to result from several years’ occupational exposure to cytostatic drugs.