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Cancer drugs given by drip or injection are usually made up in a hospital pharmacy, inside a sealed cabinet that protects both the drug from germs and the staff from the drug. Staff wear chemotherapy gloves and gowns, use sealed transfer devices, and prepare the drip lines in the cabinet so that nurses do not have to open the drug on the ward.
Compounding hazardous drugs carries the highest exposure risk of any handling task. The NIOSH Alert (2004), endorsed by ASCO (2019) alongside USP chapter 800, OSHA and ONS, is the most detailed open standard. Drugs on the NIOSH list (2024 update) are prepared in a ventilated cabinet: where asepsis is needed, a Class II biological safety cabinet (type B2 preferred), a Class III cabinet or an aseptic containment isolator, exhausting filtered air outside where feasible. Staff wear double chemotherapy-tested gloves, changed every 30 minutes or when damaged, and a disposable, non-absorbent, closed-front gown with cuffs; the outer glove goes over the cuff. Closed-system transfer devices may reduce contamination but are not a substitute for a cabinet and are used inside one. Intravenous tubing is primed in the cabinet or in-line with drug-free fluid, never at the bedside. Work surfaces are cleaned with a deactivating agent where available and a cleaning agent before and after each activity and at the end of the shift, with protective gloves.
The evidence is weak throughout. ASCO's standards are consensus based; on external ventilation of cleanrooms it found no long-term clinical evidence and leaves it to institutions; on CSTDs it found low-quality evidence and called for a testing protocol. The Cochrane review (24 observational cluster studies, 359 hospitals, mostly PhaSeal) could draw no firm conclusions. In the UK, COSHH makes the employer responsible for assessing and controlling exposure, with monitoring where carcinogens are handled.
Why: Handling precautions only work if everyone knows which drugs need them, including new drugs not yet on the national list.
“Therefore, this list may not be all-inclusive, and employers should consider creating a facility-specific hazardous drug list.”
National Institute for Occupational Safety and Health (CDC) 2024
Why: Opening vials and drawing up drug releases droplets and vapour that a cabinet captures.
“Use a ventilated cabinet designed to reduce worker exposures while preparing hazardous drugs (see following section entitled Ventilated Cabinets).”
National Institute for Occupational Safety and Health (CDC) 2004
Why: The cabinet must protect the drug from germs and the staff from the drug at the same time.
“Therefore, when asepsis is required or recommended, use ventilated cabinets designed for both hazardous drug containment and aseptic processing.”
National Institute for Occupational Safety and Health (CDC) 2004
Why: Some drugs pass through ordinary gloves and fabric; tested gloves and a non-absorbent gown block them.
“Wear PPE (including double gloves and protective gowns) while reconstituting and admixing drugs:”
National Institute for Occupational Safety and Health (CDC) 2004
Why: Gloves become more permeable with time and damage.
“Change gloves every 30 minutes or when torn, punctured, or contaminated.”
National Institute for Occupational Safety and Health (CDC) 2004
Why: A closed device can cut leaks but has not been shown to replace the cabinet's protection.
“Remember that a closed-system transfer device is not an acceptable substitute for a ventilated cabinet and should be used only within a ventilated cabinet.”
National Institute for Occupational Safety and Health (CDC) 2004
Why: Priming with drug outside a cabinet sprays droplets where nurses and patients are.
“Have pharmacy personnel prime the IV tubing and syringes inside the ventilated cabinet, or prime them in-line with nondrug solutions—never in the patient’s room.”
National Institute for Occupational Safety and Health (CDC) 2004
Why: Drug residue on surfaces is a main route of staff exposure, and some residues need deactivating, not just wiping.
“Clean work surfaces with an appropriate deactivation agent (if available) and cleaning agent before and after each activity and at the end of the work shift.”
National Institute for Occupational Safety and Health (CDC) 2004
Why: Employers are legally responsible for keeping exposure as low as possible.
“Under COSHH, employers must assess the risks from handling cytotoxic drugs for employees and anyone else affected by this type of work, and take suitable precautions to protect them.”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Prepare drugs on a current hazardous-drug list inside a ventilated cabinet suited to aseptic containment (Class II BSC, type B2 preferred, Class III BSC or aseptic containment isolator, externally exhausted where feasible), with double chemotherapy gloves changed every 30 minutes, a closed-front non-absorbent gown, CSTDs used only within the cabinet, priming in the cabinet or in-line with drug-free fluid, and deactivation and cleaning of surfaces before and after each task (NIOSH 2004, endorsed by ASCO 2019). USP chapter 800, which ASCO reports requires CSTDs for administration and recommends them for compounding, could not be read. The sources agree in direction but none is graded, and the evidence for CSTDs (Cochrane 2018, very low certainty) and external ventilation (ASCO 2019, no long-term clinical evidence) is weak.
National Institute for Occupational Safety and Health (CDC) 2004 · National Institute for Occupational Safety and Health (CDC) 2024 · ASCO (Journal of Clinical Oncology, Celano et al.) 2019 · Cochrane Database of Systematic Reviews (Gurusamy et al.) 2018 · Health and Safety Executive (UK) 2026
Where it differs: Uses a CSTD for every transfer from vial to bag or syringe in compounding, rather than only where local risk assessment favours it.
Evidence: ASCO 2019 reports that USP 800 recommends CSTDs for sterile compounding and requires them for administration, and that some studies found fewer contaminated wipe samples after CSTDs were introduced, but rated the evidence low quality and called for a testing protocol. Cochrane 2018: very low certainty, no firm conclusions.
ASCO (Journal of Clinical Oncology, Celano et al.) 2019 · Cochrane Database of Systematic Reviews (Gurusamy et al.) 2018
Where it differs: Vents the room around the cabinet to the outside rather than recirculating its air through HEPA filters.
Evidence: ASCO 2019 found no long-term clinical evidence and leaves it to each institution as part of a suite of protective measures.
Shares Safe handling of hazardous anticancer drugs where they are given: protective equipment, closed systems, spills, waste and body fluids, Oncology pharmacy automation and compounding robots, Closed-system transfer devices for hazardous drugs (PhaSeal, ChemoLock, Equashield).
Shares Oncology pharmacy automation and compounding robots, Closed-system transfer devices for hazardous drugs (PhaSeal, ChemoLock, Equashield).
Shares Oncology pharmacy automation and compounding robots, Closed-system transfer devices for hazardous drugs (PhaSeal, ChemoLock, Equashield).
Shares Oncology pharmacy automation and compounding robots, Closed-system transfer devices for hazardous drugs (PhaSeal, ChemoLock, Equashield).
Shares Oncology pharmacy automation and compounding robots, Closed-system transfer devices for hazardous drugs (PhaSeal, ChemoLock, Equashield).
Shares Oncology pharmacy automation and compounding robots, Closed-system transfer devices for hazardous drugs (PhaSeal, ChemoLock, Equashield).
Shares Safe handling of hazardous anticancer drugs where they are given: protective equipment, closed systems, spills, waste and body fluids, Closed-system transfer devices for hazardous drugs (PhaSeal, ChemoLock, Equashield).
Shares Safe handling of hazardous anticancer drugs where they are given: protective equipment, closed systems, spills, waste and body fluids, Anticancer treatment prescribing and pharmacy verification before each cycle.