Chemotherapy Preparation and Delivery

The outside of incoming vials may carry drug residue, so shipments are unpacked with chemotherapy gloves. Compounding takes place in an externally vented, negative-pressure room, inside a biological safety cabinet or a closed isolator. The compounder wears two pairs of chemotherapy gloves tested to ASTM D6978, a gown shown to resist drug permeation, a hair cover and shoe covers. USP <800> says a closed-system transfer device (CSTD) should be used for compounding when the dosage form allows; a CSTD does not replace the cabinet. Pharmacies with high volumes may compound doses with a robotic system in a closed cabinet. The administration set is primed with drug-free fluid in the cabinet before the drug is added.

Source: USP <800> (official 1 Dec 2019, FAQ January 2026); Power LA, Coyne JW. ASHP, Am J Health Syst Pharm 2018;75:1996-2031 (PMID 30327293)

The outside of the prepared dose is wiped, labelled and placed in a sealed plastic bag; it goes to the ward in a shatter-proof, lidded, cleanable container. USP <800> does not allow liquid or antineoplastic hazardous drugs to be sent by pneumatic tube. A spill kit is at hand during transport. For a light-sensitive drug the bag is covered with an opaque sleeve right after compounding, and the sleeve stays on until administration ends; the product information says which drugs need it. For example, dacarbazine in PVC bags was found stable for 2 hours in daylight and for 72 hours when wrapped in foil.

Source: El Aatmani M et al. Am J Health Syst Pharm 2002;59:1351-1356 (PMID 12132562)

After skin antisepsis the port is accessed with a non-coring Huber needle, perpendicular to the septum. Needle length is chosen for the depth of the port and the tissue: a needle that is too short may not fully cross the septum, and the drug may leak into the surrounding tissue. The wings lie flat on the skin and are secured with the dressing. Before chemotherapy, blood return is confirmed and the line is flushed with saline; without blood return, catheter patency is assessed before administration, which matters all the more for vesicants.

Source: Sousa B et al. ESMO, Ann Oncol 2015;26 Suppl 5:v152-v168 (PMID 26314776)

The nurse wears two pairs of chemotherapy gloves and a gown. USP <800> says a CSTD must be used when administering antineoplastic drugs if the dosage form allows. The drug bag is connected by a closed connection to a multi-line set primed with drug-free fluid; sequential drugs go through the same access and no drug-filled line is primed at the bedside. The bag and line of a light-sensitive drug stay covered. When the infusion ends, the line is flushed with drug-free fluid; the set is not removed from the bag and is discarded intact as hazardous waste. Studies show less surface contamination with CSTDs; evidence on staff health outcomes is limited and of low certainty.

Source: Gurusamy KS et al. Cochrane 2018, CD012860 (PMID 29582940); Bartel SB et al. Am J Health Syst Pharm 2018;75:199-211 (PMID 29339374)

In some regimens the infusion continues at home; in FOLFOX and FOLFIRI, for example, 5-FU runs for about 46 hours through an elastomeric pump. The pharmacy chooses and fills the pump for the prescribed volume and flow rate; the elastomeric reservoir pushes the drug through a flow restrictor at a set rate, with no battery and no programming. The flow rate is affected by temperature, the viscosity of the drug and the height of the pump relative to the patient. The patient and family get written instructions on what to do in case of a leak, and a spill kit is kept at home. The finished pump and needle are removed at the hospital or by the home care team and collected as hazardous waste.

Source: ONS position statement, administration of antineoplastic therapies in the home (2020, reaffirmed 2024)

A spill kit is at hand wherever hazardous drugs are compounded, transported or administered. The area is marked off; the responder wears two pairs of chemotherapy gloves and a gown, with eye and respiratory protection when needed. Liquid is taken up with absorbent pads from the outside in; the surface is then deactivated, decontaminated, cleaned with detergent and, where needed, disinfected. All materials go into the cytotoxic waste container and the spill is documented. In Türkiye, cytotoxic and cytostatic drug waste is hazardous waste (18 01 08*); it is collected in leak-proof, lidded containers and incinerated at a licensed facility.

Source: European Commission, guidance for the safe management of hazardous medicinal products at work, 2023 (doi 10.2767/052571); Turkish Waste Management Regulation, OG 29314, 2015, Annex 4