Loading
Many cancer drugs harm the staff who handle them every day, even in tiny amounts. So nurses wear special gloves and gowns when giving them, use sealed connectors, and handle spills and waste in a set way. For a day or two after treatment some drug is in the patient's body fluids, so staff wear gloves for those too. The protection is for repeated exposure at work; you are not dangerous to be near.
The US framework is NIOSH (the 2004 Alert and the 2024 hazardous drug list), USP chapter 800 and OSHA, which ASCO's consensus standards (2019) endorse; the UK framework is COSHH, applied by HSE, with a hierarchy of control: enclosed systems, control at source, then PPE. Employers should keep a facility-specific hazardous drug list, because the NIOSH list (2024, 25 drugs added and 7 removed since 2016) may not include newer drugs.
NIOSH (2004) asks for double chemotherapy-tested gloves, a disposable gown with a closed front and closed cuffs, and goggles for all administration activities, from opening the outer bag to disposal; preparation belongs in a ventilated cabinet, tubing is primed with a non-drug fluid, and closed-system transfer devices (CSTDs) supplement but do not replace the cabinet. ASCO (2019) reports that USP chapter 800 requires CSTDs for administration and recommends them for compounding, while a Cochrane review (2018, 24 observational studies) found the evidence of benefit very low in certainty and drew no firm conclusions. Linen and excreta from patients treated within 48 hours (sometimes 7 days) are handled with two pairs of gloves and a gown. Spills follow written procedures with spill kits nearby; large spills need trained staff and a respirator, as surgical masks do not protect. ASCO asks for an alternative-duty policy for staff who are trying to conceive, pregnant or breastfeeding, and finds routine medical surveillance unsupported by evidence; HSE says monitoring is normally needed under COSHH where carcinogens are handled.
Why: New cancer drugs reach wards before national lists are updated.
“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: Protective equipment is the last line of defence; engineering controls protect everyone at once.
“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.”
Why: Everyone who touches the bag later, including porters and cleaners, needs to know.
“A label denoting HAZARDOUS DRUG, if applicable”
ASCO and the Oncology Nursing Society (JCO Oncology Practice) 2024
Why: Opening vials and powders releases droplets and particles that a cabinet captures.
“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: Skin contact with contaminated bags, tubing and surfaces is the main route of exposure for nurses.
“Wear PPE (including double gloves, goggles, and protective gowns) for all activities associated with drug administration—opening the outer bag, assembling the delivery system, delivering the drug to the patient, and disposing of all equipment used to administer drugs.”
National Institute for Occupational Safety and Health (CDC) 2004
Why: Ordinary gloves and cloth gowns let some drugs through.
“Make sure gowns have closed fronts, long sleeves, and elastic or knit closed cuffs.”
National Institute for Occupational Safety and Health (CDC) 2004
Why: Priming with the drug can spray it into the air or onto hands.
“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: They are designed to stop drug escaping when lines are connected and disconnected; whether they improve health is unproven.
“USP 800 requires use of CSTDs for nursing administration of hazardous drugs and recommends use for sterile product compounding of hazardous drugs.”
Why: Some drugs leave the body unchanged in urine, stool, vomit and sweat for a day or more.
“Wear two pairs of protective gloves and a disposable gown if you must handle linens, feces, or urine from patients who have received hazardous drugs within the last 48 hours—or in some cases, within the last 7 days”
National Institute for Occupational Safety and Health (CDC) 2004
Why: Waste bins are handled by many people who never see the drug.
“Procedures must be in place for the safe disposal of waste.”
Why: A prepared response limits spread and exposure.
“Manage hazardous drug spills according to the established, written policies and procedures for each workplace.”
National Institute for Occupational Safety and Health (CDC) 2004
Why: Surgical masks stop splashes to the mouth, not fine droplets or powder.
“Surgical masks do not provide adequate protection.”
National Institute for Occupational Safety and Health (CDC) 2004
Why: Exposure to some drugs has been linked to miscarriage in staff who handled them without protection.
“The health care setting has a policy that identifies potential alternative work options, where possible, for workers who are actively trying to conceive, are pregnant, or are breastfeeding.”
Why: Acute exposures, such as a spill on skin, need assessment and a record.
“Workers should be encouraged to report occupational health issues to employee health services at the time that they are experienced.”
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.
In the US, USP chapter 800 with NIOSH and OSHA, as endorsed by ASCO (2019): a facility hazardous drug list, ventilated-cabinet preparation, double chemotherapy gloves, impermeable gown and eye protection for administration, CSTDs for administration (required by USP chapter 800, according to ASCO), written spill and waste procedures, precautions with body fluids for 48 hours, and an alternative-duty policy. In the UK, COSHH as applied by HSE: risk assessment and a hierarchy of enclosure, control at source, then PPE. The sources differ on CSTDs (required by USP chapter 800; Cochrane 2018 found the evidence of benefit very low in certainty) and on monitoring (ASCO: routine medical surveillance has no supporting data; HSE: monitoring is normally necessary under COSHH where carcinogens are handled). USP chapter 800 and the ISOPP standards could not be read directly.
ASCO (Journal of Clinical Oncology, Celano et al.) 2019 · National Institute for Occupational Safety and Health (CDC) 2004 · National Institute for Occupational Safety and Health (CDC) 2024 · Health and Safety Executive (UK) 2026 · Cochrane Database of Systematic Reviews (Gurusamy et al.) 2018
Where it differs: Uses a CSTD for all preparation and every connection and disconnection at the bedside, rather than standard needles and open connections with PPE.
Evidence: Cochrane (2018): 24 observational cluster studies, no randomised trials, all at serious risk of bias; very low certainty evidence was insufficient to show differences in staff urine tests or surface contamination, and no firm conclusions could be drawn. ASCO (2019) calls the literature low quality and notes no standard test of CSTD performance exists. USP chapter 800 requires them for administration (as reported by ASCO).
Cochrane Database of Systematic Reviews (Gurusamy et al.) 2018 · ASCO (Journal of Clinical Oncology, Celano et al.) 2019
Where it differs: Regular health checks, blood counts or urine tests for staff who handle hazardous drugs.
Evidence: ASCO (2019) finds no data that routine surveillance improves outcomes and prefers a registry approach; HSE says monitoring is normally necessary under COSHH where there is potential exposure to carcinogens.
ASCO (Journal of Clinical Oncology, Celano et al.) 2019 · Health and Safety Executive (UK) 2026
Closed-system transfer devices are sealed connectors meant to stop chemotherapy escaping when it is prepared and given. US standards require them for giving hazardous drugs, but a Cochrane review found only weak observational studies and could not say whether they reduce staff exposure.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| ASCO endorses OSHA, USP chapter 800, the NIOSH 2004 Alert and ONS standards “The Expert Panel endorses a majority of the standards for safe handling of hazardous drugs as issued by the US Occupational Safety and Health Administration,” | Consensus-based standard | ASCO (Journal of Clinical Oncology, Celano et al.) 2019 |
| Routine ongoing medical surveillance: role unclear “The role of routine ongoing medical surveillance programs that include medical screening, laboratory testing, or other biologic monitoring is unclear, because there are no published data to reliably inform a standard or best practice.” | Consensus-based standard | ASCO (Journal of Clinical Oncology, Celano et al.) 2019 |
| CSTD plus safe handling versus safe handling alone “Currently, no firm conclusions can be drawn on the effect of CSTD combined with safe handling versus safe handling alone due to very low certainty evidence available for the main outcomes.” | very low certainty (GRADE) | Cochrane Database of Systematic Reviews (Gurusamy et al.) 2018 |
| Order of control measures under COSHH “Measures to control exposure should be applied in the following order: use totally enclosed systems where reasonably practicable control exposure at source, for example, by using adequate extraction systems and appropriate organisational measures issue personal protective equipment where adequate control cannot be achieved by other measures alone” | UK regulation (COSHH) | Health and Safety Executive (UK) 2026 |
Shares Oncology pharmacy automation and compounding robots, Closed-system transfer devices for hazardous drugs (PhaSeal, ChemoLock, Equashield), Cytotoxic chemotherapy.
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 Anticancer treatment administration checks at the chair: assessment, independent double checks and line tracing, Oncology pharmacy automation and compounding robots, Cytotoxic chemotherapy.
Shares Oncology pharmacy automation and compounding robots, Closed-system transfer devices for hazardous drugs (PhaSeal, ChemoLock, Equashield).
Shares Ifosfamide, Cyclophosphamide, Cytotoxic chemotherapy.
Shares Ifosfamide, Cytotoxic chemotherapy.