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Chemotherapy Safety: To Boldly Go
Joseph A. Kalis, Pharm.D.
PGY-2 Oncology Pharmacy Resident
St. Luke’s Mountain States Tumor Institute
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Objectives
• Describe why extra safety measures are
needed with chemotherapy
• Recognize common oral chemotherapy
medications and understand oral
chemotherapy safety precautions
• Describe the role of the pharmacy technician
in maintaining chemotherapy safety
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Safety
• Highly prevalent in
today’s society
• Key component of
good healthcare
• Self-explanatory?
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Chemotherapy: Changing Times
• Initial Meaning: chemical treatment of disease
– Antibiotics
– Painkillers
• Current Meaning: antineoplastic agents
– Individual drugs
– Regimens
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Chemotherapy Concepts
• Anti-neoplastic?
• Target: rapidly dividing cells
• Types of Chemotherapy
– Cell Cycle Specific
– Cell Cycle Non-specific
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Goals of Chemotherapy
DESTROY CANCER
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“Hazardous Drug”
• NIOSH/ASHP Definition:
1. Carcinogenicity
2. Teratogenicity/Developmental Toxicity
3. Reproductive Toxicity
4. Organ Toxicity at low doses
5. Genotoxicity
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Chemotherapy Concerns
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Chemotherapy Safety
• ASCO/ONS Chemotherapy Standards – Multi-disciplinary focus
– Address safe use of chemotherapy • Ordering/Prescribing
• Preparation
• Administration
• USP <797> – Pharmacy-specific focus
– Governs preparation of sterile products • IV medications
• Chemotherapy
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Chemotherapy Safety Roles
• Physician
– Assess patient
– Diagnose type of disease
– Determine appropriate chemotherapy
• Pharmacist
– Review physician orders; serve as double-check
– Educate and counsel patients
– Serve as drug information resource
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Chemotherapy Safety Roles
• Pharmacy Technician
– Prepare chemotherapy and pre-meds
– Serve as double-check for pharmacist
– Maintain sterility of compounded preparations
• Nurse
– Administer medications
– Assess patient for response and reactions
– Serve as double check to physician & pharmacist
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Chemotherapy Safety Roles
• Patient
– Consent to treatments, if desired
– Play active role in understanding treatment
– Ask questions
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Forms of Chemotherapy
• Intravenous (IV)
• Oral (PO)
• Intrathecal (IT)
• Intra-arterial
• Intra-cavitary
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INTRAVENOUS
CHEMOTHERAPY
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IV Chemotherapy
• Most commonly used form of chemotherapy
• Regimens for wide variety of cancers
• Extra safety precautions are paramount
– Special equipment
– Hazardous drugs
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Preparing IV Chemotherapy
• Sterile Compounding Hood
– Vertical airflow
– Negative pressure
• Personal Protective Equipment (PPE)
– Gloves
– Gowns
– Eye protection
Chemotherapy-specific
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Sterile Compounding Hoods
• Laminar Flow
• Compounding non-
hazardous sterile
preparations
• Not for use with
chemotherapy
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Sterile Compounding Hoods
• Vertical-flow
• Compounding
hazardous sterile
preparations
• For use with
chemotherapy
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Personal Protective Equipment
Chemotherapy specific products
1. Gloves no permeability
– Chemotherapy can permeate standard gloves
– Double gloving recommended (NIOSH)
2. Gown low permeability material
3. Goggles
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ASCO/ONS Labeling Requirements
• Chemotherapy is labeled immediately upon preparation with:
– 2 patient identifiers
– Full generic name
– Route
– Total dose to be given
– Total volume
– Date and time of preparation
– Date and time of expiration if not for immediate use
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IV Chemotherapy Trivia
Common Drugs
• Cisplatin
• Vincristine
• Paclitaxel
• Rituximab
• Cyclophosphamide
Which drug...
• Is fatal if given intrathecally?
• Requires special tubing and
IV bags?
• Causes hypersensitivity
reactions?
• Is absorbed through the
skin?
• Cannot be mixed in D5W?
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ORAL CHEMOTHERAPY
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Oral Chemotherapy
• Rapidly growing area of cancer treatments – 25% of developmental chemotherapies
– Ease of use
• Used in treatment of: – Brain Cancer
– Lung Cancer
– Colon Cancer
– Breast Cancer
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Oral Chemotherapy Safety
• Misconception of Safety
– Familiarity with oral medications
– Self-administration
• Ease of Exposure
– Tablets/Capsules
– Storage
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Oral Chemotherapy Precautions
• Handling – Use gloves
– Wash hands before and after gloving
• Counting – Hand counting only
– DO NOT use automatic counting machines
– Wash counting trays, etc after use
• Storage – Separate from non-chemotherapy agents
– Follow manufacturer’s instructions
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Common Oral Chemotherapy Agents
• Xeloda® Capecitabine (Colon/Breast)
• Temodar® Temozolomide (Brain)
• Tarceva® Erlotinib (Lung)
• Zytiga® Abiraterone (Prostate)
• Gleevec® Imatinib (Lung)
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Five Rights
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Review Questions
• Which of the following medication(s) requires oral chemotherapy safety precautions?
i. Lisinopril (Prinivil)
ii. Imatinib (Gleevec)
iii. Cyclophosphamide (Cytoxan)
iv. Temozolomide (Temodar)
A. I only
B. III only
C. II,III,IV
D. II and IV
E. I,II,III,IV
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Review Questions
• What type of hood is used to prepare IV
chemotherapy?
A. Laminar-Flow hood
B. Vertical-Flow hood
C. Monk’s hood
D. Biologic Safety Cabinet
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Review Questions
• In which of the following situations should a
technician intervene and question a
prescription for chemotherapy?
A. When the dose is unusually large
B. If the usual pre-medications for an IV chemotherapy are
missing
C. If the medication is new or unfamiliar
D. All of the above
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Questions?
Pike’s Peak, from Colorado Springs
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References
1. Neuss MN, Polovich M, McNiff K, et al. 2013 Updated American Society of Clinical
Oncology/Oncology Nursing Society Chemotherapy Administration Standards Including Standards
for the Safe Administration of and Management of Oral Chemotherapy.
2. Pharmaceutical compounding-sterile preparations (general information chapter 797). In: The United
States Pharmacopeia, 36th rev., and The National Formulary, 31st ed. Rockville, MD: The United States
Pharmacopeial Convention, 2012.
3. American Society of Health-System Pharmacists. ASHP Guidelines on Handling Hazardous Drugs.
Am J Health-Syst Pharm. 2006;63:1172-93.
4. Weingart S, Brown E, Bach PB, et al. NCCN Task Force Report: Oral Chemotherapy. J Natl Compr
Canc Netw. 6:S1-S14, 2008 (Suppl 3).
5. Cyclophosphamide. Lexi-Comp, Inc. Lexi-Drugs. Lexi-Comp 2013; Accessed 20 August 2013.
6. Rituximab. Lexi-Comp, Inc. Lexi-Drugs. Lexi-Comp 2013; Accessed 20 August 2013.
7. Cisplatin. Lexi-Comp, Inc. Lexi-Drugs. Lexi-Comp 2013; Accessed 20 August 2013.
8. Vincristine. Lexi-Comp, Inc. Lexi-Drugs. Lexi-Comp 2013; Accessed 20 August 2013.
9. Paclitaxel. Lexi-Comp, Inc. Lexi-Drugs. Lexi-Comp 2013; Accessed 20 August 2013.