Breast Cancer Chemotherapy | Chemotherapy Guidelines Does this really matter?

There are variety of care settings wherein chemotherapy is administered. Most of the cancer patients receive systemic chemotherapy in an ambulatory care setting or in a day care unit designed to care for patients requiring lengthy infusions. Admission in Hospital is reserved for patients who require intensive monitoring or are acutely ill. The shift to outpatient ambulatory care services has grown out of the need for more efficient and economical health care.Exposure to cytotoxic drugs is known to be potentially hazardous to the health. Cytotoxic drugs may enter the body by three possible routes: Inhalation, Ingestion and Skin contact. These are most likely to occur with injectable agents during either their preparation or administration. Therefore, to prevent the risk, adequate precautions must be taken by a pharmacist while admixturing chemo drugs.

Adequate precautions must be taken during admixture of cytotoxic drugs.

Wear latex powder free long cuff gloves while preparing chemotherapy drugs. Wear a gown that is low or non-permeable, long sleeve, cuffed and solid fronted and use aerosols free mask. Work over a suitable container to prevent the spread of any spillage. Prevent high pressure being generated inside sealed vials - when fluids are introduced an equivalent volume of air should be withdrawn or a venting needle with a hydrophobic filter may be used if available.

Ampoules should be directed away from the face and covered with a suitable pad or cotton when broken open. Diluent fluids should be introduced slowly into open-ended ampoules or vials, running it down the vessel wall and ensuring the drug powder is moist before shaking. When excess air is expelled from a filled syringe it should be exhausted into a pad and not straight into the atmosphere. If excess drug is to be expelled from a filled syringe it should be removed first and sterile cotton wool placed over the end of the syringe to prevent possible scatter of aerosol droplets. Luer lock fittings should be used in preference to push connections on syringes, tubing and I.V. sets. Label all prepared bottles and it is mandatory. Admix all cytotoxic drugs in biological safety cabinet (laminar air flow) that meets standards and it is inspected appropriately. Check the reconstitute or diluents for the particular drug and the concentration in which it is to be reconstituted.

A checklist must be kept ready before preparing the cytotoxic drugs. Name of the drug, company name, active salt, strength, expiry date, Patient name, age and patient ID number, number of chemotherapy cycle, approximate cost of the drug, Drug delivery route and access devices. The other things to be kept in mind are Solvent and its concentration in which it is to be mix, Infusion or diluent fluids (D5%W / NS / RL / DNS) with which to be mixed, Availability of drug delivery access and Cross marking of the pack and label of the vial / ampoule. Drug dose is to be administered according to body surface area and body weight.

Proper disposable management should be done. All the waste materials like syringe, needle, mask and gloves should be disposed carefully in cytotoxic disposal bags. Changes of gloves and mask should be done after each admixture process. The syringes should also change after each drug admixing. A standard procedure is to be made and followed for disposals of waste materials. The disposal bags should print with cytotoxic drug. Cytotoxic waste is highly hazardous and should never be land filled or discharged into the sewerage system. Disposal options include the following: Safely packaged but outdated drugs and drugs that are no longer needed should be returned to the supplier. This is currently the preferred option for countries that lack the facilities for incineration. Drugs that have been unpacked should be repackaged in a manner as similar as possible to the original packaging and marked “outdated” or “not for use”.

Full destruction of all cytotoxic substances may require temperatures up to 1200°C; Incineration at lower temperatures may result in the release of hazardous cytotoxic vapours into the atmosphere. The cytotoxic admixture should be done by a proper procedure in all the cancer institutes. This is the area where the pharmacist can utilise his knowledge of pharmaceutics. Working with cytotoxic drugs requires adequate knowledge and skill. Chemo drugs are very toxic for which proper care and precautions is to be taken while handling, preparing, administering and disposing.