Preparation Of Antineoplastic Drugs Research Articles

Implementation and Evaluation of Safe Handling Precautions Training for Oncology Nurses: An Experimental Design

Antineoplastic drugs are a hazard for both patients and healthcare workers. Health workers may be exposed to antineoplastic drugs by inhalation, ingestion or direct skin contact during the preparation, transport, administration, storage and disposal of antineoplastic drugs. The study aims to evaluate the impacts of the training on the safe handling precautions and oxidative stress parameters for oncology nurses. The study was an experimental study without a control group. This study included 23 oncology nurses who were involved in the preparation and administration of antineoplastic drugs. Training effectiveness was evaluated with the safe handling precautions questionnaire and blood samples of oncology nurses. After the training, the frequency of using the closed system transfer devices and changing the chemotherapy glove every 30 min in preparation of antineoplastic drugs significantly increased in the post-test. The post-test 8-hydroxy-2′-deoxyguanosine mean of the nurses was found to be significantly lower than pre-test and follow-up. The training program provided a positive contribution to increasing the use of safe handling precautions and reducing oxidative damage. According to the results of this study, the training program can be used to develop protective health behaviors, and to reduce occupational exposure.

Environmental and Product Contamination during the Preparation of Antineoplastic Drugs with Robotic Systems

Abstract Background Robotic systems are designed to minimize the exposure to antineoplastic drugs during automated preparation. However, contamination cannot be completely excluded. The aim of the study was to evaluate the contamination with antineoplastic drugs on the working surfaces and on the outer surface of the ready-to-use products (infusion bags and syringes) during automated preparation with different versions of a robot and manual preparation. Methods Surface contamination with platinum (Pt) and 5-fluorouracil (5-FU) was measured by wipe sampling and quantified by voltammetry for Pt and GC-MS for 5-FU. Sampling was performed on pre-defined locations in the working areas before and after preparation of standardized test products. The outer surfaces of Pt- or 5-FU-containing infusion bags and 5-FU-containing syringes were sampled without and after manual capping. Results Overall, the surface contamination in the working areas of the robotic system ranged from 0.4 to 114 pg/cm2 for Pt and from 1.3 to 1,250,000 pg/cm2 for 5-FU. The highest contamination levels were detected after preparation on the gripper of the robotic arm and on the surface beneath the dosing device. In most cases, measured concentrations were higher after preparation. Outer surfaces of infusion bags prepared with the robotic system were less contaminated than manually prepared bags. Contamination on the outer surface of syringes varied depending on the procedure adopted. Conclusions The risk of contamination is localised inside the working area of the robot. The outer surfaces of products were only marginally contaminated. Cleaning procedures of the working area are to be further investigated. An effective decontamination procedure for the working area of the robot and automated capping of filled syringes should be developed to further minimize the occupational risk.

1460P - Robotic anticancer drug compounding assist system for the preparation of injectable antineoplastic drugs

Background: Many antineoplastic drugs are known to be mutagenic or teratogenic. Medical personnel handling antineoplastic drugs are at a high risk of occupational exposure. Therefore, in collaboration with Yaskawa Electric Corporation and Nikka Micron Co., Ltd, we developed the Cancer Drug Compounding Assist System (CDCAS). The CDCAS is an automated robotic system designed to efficiently facilitate the accurate preparation of drugs based on dose. In this study, we evaluated the CDCAS for accuracy, site contamination, and washing performance in the preparation of antineoplastic drugs. Methods: 5-Fluorouracil (5-FU; 600, 800, or 1200 mg) was added to 100 mL of saline; 5 samples of each formulation were prepared. The weight of the mixed drugs prepared using the CDCAS was compared to those prepared by a pharmacist, and the accuracy of each preparation was calculated in terms of percentage relative error. The acceptable variance was set at ± 5%. To test for contamination, cyclophosphamide (800 mg) was continuously added to 50 bags of 100 mL saline solution. Then, 25 locations inside the isolator were identified for measurement. Cyclophosphamide was collected from those sites by using a sampling sheet method. Twenty of those samples revealed adherence of 5-FU (300 µL) to the infusion bag surface. Ozonated water was used to wash 5-FU from the surface of the infusion bags. After the washing process, any 5-FU remaining on the infusion bag surface was recovered via a wiping method. Results: The average weight error ratio for the CDCAS and the pharmacist was −0.62% and 2.69%, respectively. Contamination of cyclophosphamide was confirmed at eight sites. Pollution of 5-FU was confirmed for two samples, and the removal rate was ≥ 99.9%. Conclusions: Our study demonstrated that the CDCAS’s preparation accuracy and cleaning performance are within acceptable limits. Thus, the CDCAS could be used to potentially reduce occupational exposure to antineoplastic drugs. Legal entity responsible for the study: Satohiro Masuda Funding: None Disclosure: All authors have declared no conflicts of interest.

Evaluation of real-time data obtained from gravimetric preparation of antineoplastic agents shows medication errors with possible critical therapeutic impact: Results of a large-scale, multicentre, multinational, retrospective study

Medication errors are a significant cause of morbidity and mortality especially with antineoplastic drugs, owing to their narrow therapeutic index. Gravimetric workflow software systems have the potential to reduce volumetric errors during intravenous antineoplastic drug preparation which may occur when verification is reliant on visual inspection. Our aim was to detect medication errors with possible critical therapeutic impact as determined by the rate of prevented medication errors in chemotherapy compounding after implementation of gravimetric measurement. A large-scale, retrospective analysis of data was carried out, related to medication errors identified during preparation of antineoplastic drugs in 10 pharmacy services ("centres") in five European countries following the introduction of an intravenous workflow software gravimetric system. Errors were defined as errors in dose volumes outside tolerance levels, identified during weighing stages of preparation of chemotherapy solutions which would not otherwise have been detected by conventional visual inspection. The gravimetric system detected that 7.89% of the 759060 doses of antineoplastic drugs prepared at participating centres between July 2011 and October 2015 had error levels outside the accepted tolerance range set by individual centres, and prevented these doses from reaching patients. The proportion of antineoplastic preparations with deviations >10% ranged from 0.49% to 5.04% across sites, with a mean of 2.25%. The proportion of preparations with deviations >20% ranged from 0.21% to 1.27% across sites, with a mean of 0.71%. There was considerable variation in error levels for different antineoplastic agents. Introduction of a gravimetric preparation system for antineoplastic agents detected and prevented dosing errors which would not have been recognized with traditional methods and could have resulted in toxicity or suboptimal therapeutic outcomes for patients undergoing anticancer treatment.

PMD22 - Closed-System Transfer Device for Preparation of Antineoplastic Drugs in a Malaysian Public Hospital: Is it Truly Cost Saving?

PMD22 - Closed-System Transfer Device for Preparation of Antineoplastic Drugs in a Malaysian Public Hospital: Is it Truly Cost Saving?

アイソレーターと抗がん剤自動調製ロボットを使用した新たな抗がん剤調製業務の検討

Recent guidelines issued by the Japanese Society of Hospital Pharmacists recommend the use of biological safety cabinets (BSCs) and personal protective equipment (PPE) to prevent medical staff from being exposed to antineoplastic drugs during drug preparation. However, wearing PPE costs pharmacists additional time and labor during the preparation process. Since 2012, Nagoya City University Hospital has instituted the use of compounding aseptic containment isolators (CACIs, ChemoSHIELD) and a robotic system (CytoCare) for use during antineoplastic drug preparation. We investigated the effects of introducing CACIs and CytoCare on preventing antineoplastic drug exposure and on pharmacist efficiency. To evaluate workplace contamination, antineoplastic drug residues were measured using the wipe method. We also measured antineoplastic drug urine levels in pharmacists involved in the work. The levels of three antineoplastic drugs (cyclophosphamide, ifosfamide, gemcitabine) were measured using ultra-performance liquid chromatography-tandem mass spectrometry. Further, we investigated the stand-by time of pharmacists involved in the preparation of chemotherapeutic drugs. The results demonstrated that, compared with conventional class II BSCs, CACIs demonstrated decreased workplace contamination. Before CACIs introduction, antineoplastic drugs were detected in 3 of 12 urine samples, whereas after CACIs introduction, antineoplastic drugs were not detected in the urine of pharmacists. Additionally, the CACI and CytoCare systems significantly reduced the stand-by time of pharmacists, compared with BSCs (P < 0.001). Therefore, a combination of CACIs and robotic systems allows safe and efficient chemotherapeutic preparation.

Cost Analysis of Using a Closed-System Transfer Device (CSTD) for Antineoplastic Drug preparation in a Malaysian Government-Funded Hospital

Background:Apart from reducing occupational exposure to cytotoxic hazards, the PhaSeal® closed-system transfer device (CSTD) can extend the beyond-use dates (BUDs) of unfinished vials of antineoplastic drugs for up to 168 hours (seven days). In this study, the total material cost incurred by its use in a Malaysian government-funded hospital was calculated.Methods:A list of vial stability following initial needle punctures of 29 commonly-used antineoplastic drugs was compiled. The amount of the materials used, including drugs, infusion bottles, the PhaSeal® CSTD and other consumables, was recorded on a daily basis for three months in 2015. The total cost was calculated based on the actual acquisition costs, and was compared with that of a hypothetical scenario, whereby conventional syringe-needle sets were used for the same amounts of preparations.Results:The use of the PhaSeal® CSTD incurred a cost of MYR 383,634.52 (USD 92,072.28) in three months, representing an average of MYR 170.5 (USD 40.92) per preparation or an estimated annual cost of MYR 1,534,538.08 (USD 368,289.14). Compared with conventional syringe-needle approach, it is estimated to lead to an additional spending of MYR 148,627.68 (USD 35,670.64) yearly.Conclusion:Although there was a reduction of drug wastage achieved by extending BUDs of unfinished vials using the PhaSeal® CSTD, cost saving was not observed, likely attributable to the wide use of lower-priced generic drugs in Malaysia. Future studies should further evaluate the possibility of cost saving, especially in health settings where branded and high-cost antineoplastic drugs are more commonly used.

Implementation of a robot for the preparation of antineoplastic drugs in the Pharmacy Service

To describe the implementation of a robot for the preparation of antineoplastic drugs in the Pharmacy Service and to be able to analyze the added value to pharmacotherapy. The implementation was carried out in June 2012 at a tertiary level Hospital, taking place in two periods: 1- test period with the installation of the robot, with technical configuration of the equipment and validation of 29 active ingredients and the integration of electronic prescribing software with the robot application (9 months). 2- Usage period (22 months). On the other hand, training was given to pharmacists and nurses. The robot uses image recognition, barcode identification and gravimetric controls for proper operation. These checks provide information about the error ratio in the preparation, with a margin of ± 10%, which after a pilot study was restricted to a range of ±4%. The robot was programmed to recognize bags, infusion pumps, syringes and vials. The added value was assessed for 31 months by identifying preparation's errors. 11,865 preparations were made by the robot, which meant approximately 40% of all antineoplastic prepared from 29 different active ingredients. 1.12% (n=133) of the errors were identified by the robot and therefore didn't reach the patient (negative desviation - 4%). These errors were corrected manually. The implementation of a robot in the preparation of antineoplastic drugs allows to identify errors therefore preventing them to arrive to the patient. This promotes safety and quality of the process, reducing the exposure to cytotoxic drugs from the manipulator.

To create a cleanroom controlled environment using a mobile air decontamination unit for the preparation of antineoplastic drugs.

To use a mobile air decontamination unit (MADU) for a microbial destruction and decreased particle burden making a cleanroom controlled environment in a Centralized Chemotherapy Preparation Unit (CCPU). Good manufacturing practices (GMP) in France specify that the ambient air in the vicinity of a class III biosafety cabinet (isolator) complies with air cleanliness ISO 8 level in CCPU. This guideline has a significant impact because implementing a dedicated air handling unit (AHU) brings some engineering constraints and generates substantial additional costs. Authors have previously studied some technical and economical aspects to evaluate the feasibility of the MADU option. Using a MADU was the chosen option. Qualification of the CCPU showed that results were in compliance with the French GMP. After one year of use, the efficiency of the MADU was confirmed. According to these results, using a MADU constitutes a beneficial option for CCPU previously equipped with an isolator when compared to renovation work involving a standard built-in AHU.

Automated preparation of chemotherapy: Quality improvement and economic sustainability

The quality and economic implications of manual versus automated preparation of antineoplastic drugs were compared. This four-week study evaluated 10 routinely used antineoplastic drugs (fluorouracil, cyclophosphamide, gemcitabine, trastuzumab, bevacizumab, oxaliplatin, cisplatin, paclitaxel, irinotecan, and etoposide) prepared by manual and automated procedures. The accuracy of the dose of the active ingredient was calculated in terms of percent relative error for the difference between the nominal value indicated on the prescription and the actual value of the drug in the finished product. A comparative economic analysis of the manual and automated preparation procedures was performed by calculating the mean unit cost for each preparation at different production levels. Participating pharmacists and technicians completed a survey rating each preparation method in terms of performance, operator satisfaction, technology, and safety. Of the 2500 i.v. antineoplastic preparations made in the pharmacy during the four-week study period, 681 were analyzed (348 using the automated procedure and 333 manually). Of these, 17 varied by more than 5% of the prescribed dose, and 1 varied by over 10%. Accuracy, calculated in terms of average percent relative error, was the highest and lowest during manual preparation. The preparation time for individual drugs was always higher when prepared using the automated procedure. A lower mean variable unit cost was observed for preparations made using the automated procedure. Questionnaire results revealed that operators preferred the automated procedure over the manual procedure. Both the automated and manual procedures for preparing antineoplastic preparations proved to be accurate and precise. The automated procedure resulted in substantial advantages in terms of quality maintenance standards and risk lowering.

Environmental contamination, product contamination and workers exposure using a robotic system for antineoplastic drug preparation

Environmental contamination, product contamination and technicians exposure were measured following preparation of iv bags with cyclophosphamide using the robotic system CytoCare. Wipe samples were taken inside CytoCare, in the clean room environment, from vials, and prepared iv bags including ports and analysed for contamination with cyclophosphamide. Contamination with cyclophosphamide was also measured in environmental air and on the technicians hands and gloves used for handling the drugs. Exposure of the technicians to cyclophosphamide was measured by analysis of cyclophosphamide in urine. Contamination with cyclophosphamide was mainly observed inside CytoCare, before preparation, after preparation and after daily routine cleaning. Contamination outside CytoCare was incidentally found. All vials with reconstituted cyclophosphamide entering CytoCare were contaminated on the outside but vials with powdered cyclophosphamide were not contaminated on the outside. Contaminated bags entering CytoCare were also contaminated after preparation but non-contaminated bags were not contaminated after preparation. Cyclophosphamide was detected on the ports of all prepared bags. Almost all outer pairs of gloves used for preparation and daily routine cleaning were contaminated with cyclophosphamide. Cyclophosphamide was not found on the inner pairs of gloves and on the hands of the technicians. Cyclophosphamide was not detected in the stationary and personal air samples and in the urine samples of the technicians. CytoCare enables the preparation of cyclophosphamide with low levels of environmental contamination and product contamination and no measurable exposure of the technicians.

Environmental and Biological Monitoring of Platinum-Containing Drugs in Two Hospital Pharmacies Using Positive Air Pressure Isolators

Environmental and biological monitoring of platinum containing drugs was implemented in two French hospital pharmacies using positive air pressure isolators and having similar working procedures when preparing antineoplastic drugs. Wipe sampling of surfaces, gloves, and vials was performed in the preparation room and in storage areas. All employees involved in the preparation of antineoplastic drugs were tested for urinary platinum on Monday before work and Friday after shift. Only traces of platinum were detected on surfaces in the preparation room outside the isolators (less than 1.61 pg cm(-2)). However, in one center, significant contamination was found in the storage area of the drug vials, which can most likely be linked to the rupture of a platinum vial and due to inefficient cleaning procedures. Surfaces inside the isolators were found to be contaminated (maximum: 198.4 pg cm(-2)). A higher level of contamination was detected in one pharmacy and could be explained by the lack of overgloving with regular changes during the preparation process. Nitrile gloves used during drug handling outside the isolator showed the highest platinum concentration (maximum: 5.86 ng per pair). With regards to platinum urine concentration, no significant difference was found between exposed and unexposed pharmacy personnel. Isolator technology combined with individual protective measures seems to be efficient to protect workers from occupational exposure to antineoplastic drugs, whereas specific individual protective procedures implemented were focussing on the risk of handling vials outside the isolator (e.g. high frequency of glove changing). Moreover, overgloving inside the isolator would contribute to substantially decrease inner surface contamination and should be recommended in order to limit the transfer of chemical contamination to the end products.

The effect of intravitreal bevacizumab injection in neovascular macular degeneration

BackgroundBevacizumab is a monoclonal antibody that binds vascular endothelial growth factor. It reduces angiogenesis and vascular permeability. In Italy it is approved for colorectal, lung, breast and renal cancer. In...

Actual Conditions of the Mixing of Antineoplastic Drugs for Injection in Hospitals in Osaka Prefecture, Japan

We conducted a questionnaire survey in order to grasp the actual conditions under which antineoplastic drugs are mixed for injection in hospitals. Questionnaires were sent to all 155 hospitals with 100 or more beds for general patients in Osaka Prefecture, Japan. The response rate was 69.0%. Mixing of antineoplastic drugs was done in 81.3% of the hospitals. The questionnaire was answered by doctors in 17.2% of the hospitals with antineoplastic drugs, nurses in 11.5%, and pharmacists in 70.1%. Mixing of antineoplastic drugs was done by doctors in 58.6% of the hospitals, nurses in 44.8%, and pharmacists in 63.2% (multiple answers). Occupational exposure to antineoplastic drugs was recognized in 97.7% of the hospitals. The mean frequency of the mixing operation was 8.8 d per month per worker. The mean number of antineoplastic drugs handled was 7.4 types. Guidelines for the safe handling of antineoplastic drugs were used in 52.8% of the hospitals and a biological safety cabinet was available in 57.4%. Gloves, mask, gown and goggles were used in 82.7, 69.0, 62.1 and 36.8% of the hospitals, respectively, but no personal protective equipment was used in 10.1%. The safety precautions of the hospitals in which the number of beds was small tended to be fewer than those of the hospitals in which the number of beds was large. Used vials and ampoules were disposed of as clinical, infectious or exclusive antineoplastic drug waste by 74.7% of the hospitals. Safety measures for handling the excrement of patients treated with antineoplastic drugs were performed in 8.0% of the hospitals. In 43.7% of the hospitals, the responders had experienced accidents during antineoplastic drug preparation, such as drugs adhering to hands or eyes, drug leakage, accidental injection and cutting by ampoules. Because of the adverse effects of antineoplastic drugs, all hospitals in which the healthcare workers handle them should promote safety precautions.

Mono‐ and diiodocyclophosphamide as possible internal standards for cyclophosphamide quantification: characterization by ion trap multi‐stage mass spectrometry and effects of iodine‐chlorine substitution on the fragmentation pattern

Hospital personnel involved in antineoplastic drug preparation and administration to patients are exposed to large amounts of these drugs. Labour legislation indicates the necessity of planning monitoring strategies aimed at prevention and/or reduction of drug exposure. Monitoring strategies consist of quantitative determinations of indicators, present in environmental and biological matrices. Among the antineoplastic drugs widely used, cyclophosphamide (CP) has been identified as a suitable indicator of potential exposure to mixtures of antineoplastic drugs. Many literature methods for quantitative analysis of CP involve either liquid (LC) or gas chromatography (GC) with mass spectrometry (MS), both of which require use of a suitable internal standard. The present work focuses on the synthesis of mono- and diiodocyclophosphamide (CPI and CPI(2)) to be used as internal standard. These compounds were analyzed by GC/EI-MS/MS and LC/ESI-MS(n) using ion trap mass spectrometry. The product ion mass spectra are interpreted in terms of proposed structures of fragment ions. Iodine-chlorine substitution resulted in a weakening of the carbon-halogen bond with a noteworthy influence on the ion fragmentation processes. The proposed suitability of CPI and CPI(2) as internal standards was based on similarities to CP as regards ionization and fragmentation processes. The results obtained suggest that CPI could be used as internal standard for CP quantification by LC/ESI-MS/MS, and CPI(2) for GC/EI-MS/MS analyses.

Errors evolution and analysis in antineoplastic drug preparation during one year.

We analyzed the errors occurring in the preparation circuit of cytotoxic mixtures of the Centralized Cytotoxic Preparation Unit during one year. Analysis of their evolution meant the investigation of twenty parameters susceptible to error. Each parameter was considered one error opportunity. Error has been defined either by the lack of data or mistake in the controlled parameter. In 4,734 preparations (94,680 parameters) there were 314 errors. The percentage of error per parameter in the first month of study was 0.74; at sixth was 0.34 and the last month was 0.26. Only in four months the day of maximum number of preparations coincided with the day of maximum number of errors. We conclude that the percentage of errors in the preparation process is low with a tendency to decrease and that the number of daily preparations is not the single factor that influences the production of errors.

Certification program in antineoplastic drug preparation for pharmacy technicians and pharmacists

A formal training program for technicians who prepare cytotoxic agents and pharmacists who check the doses is described. To handle an overwhelming workload in an oncology satellite pharmacy and to enable the pharmacists there to increase their clinical involvement, a program was developed to train technicians to prepare antineoplastic doses and pharmacists to check the technicians' work. The program consists of two days of classroom instruction, three weeks of hands-on training, and a written examination. In addition to handling and preparation of antineoplastic drugs, other topics related to oncology are covered to give the participants a better understanding of cancer and its treatment. The technicians must complete a refresher program annually. From 1991 to 1993, 15 pharmacists and 14 technicians and pharmacy students completed the program. The technicians have taken on additional responsibilities in the satellite pharmacy, including managing the inventory of oncology drugs. Implementation of a comprehensive cancer chemotherapy training class for technicians and pharmacists has benefited the pharmacy in terms of labor and inventory control.

The risks of handling cytotoxic drugs

Presuming that preparation of antineoplastic drugs without proper protection may lead to mutagenic urine (of which the effects are uncertain), one has to take great care when preparing these drugs. Apart from Norway no other country has national regulations issued by the government for handling cytostatic agents. Many organizations in various countries have made their own guidelines, which may be adapted to the situations in local hospitals. The following recommendations have been compiled after a review of the literature. They reflect a personal set of guidelines for preparation, administration and disposal of cytotoxic drugs. They are probably the minimum precautions that should be taken, and have not been approved by any committee or agency. Further precautions must first have their potential benefit weighed against probable inconvenience and additional costs.

Robotic system for i.v. antineoplastic drug preparation: Description and preliminary evaluation under simulated conditions

A robotic system for preparing doses of i.v. antineoplastic drugs is described, and measurements made with the system are compared for accuracy and reproducibility with those made by pharmacists and technicians. System hardware consists of a robotic arm, a 16-bit microcomputer, a bar-code reader, a voice synthesizer, and an electronic balance. The software includes a menu-driven main program, executable files for each robotic activity, and an interface to allow control to pass between the program and the files. The program has routines for matching the software to the hardware; for entering information about the patient, the name of the drug ordered, and the dose; for checking the dose; for selecting the number and size of the vials to be used; for specifying the manipulations of the robotic arm; for printing labels; and for maintaining records. The robot fills an order by getting and placing a vial, inserting a needle into it and withdrawing the drug, weighing the vial, agitating the container to dissolve its contents, reading a bar code, placing a syringe in a syringe manipulator, and getting an i.v. container and injecting the drug into it. Detection of any errors by a series of self-checks arrests execution of an order. No significant differences in accuracy and precision were found between the robotic system and humans performing the same tasks under simulated conditions. The robotic system required less time than humans and eliminated the possibility of direct human contact with the i.v. admixture. Under simulated conditions, a robotic system developed to assist in the preparation of i.v. antineoplastic drugs was as accurate as a manual system and was more time efficient.

Handling antineoplastic-drug admixtures at cancer centers: Practices and pharmacist attitudes

Results of a 1986 national survey of handling practices for antineoplastic drugs at cancer centers and pharmacists' attitudes toward the importance of recommended practices are reported. A sample of 323 hospitals representing the 27 comprehensive cancer centers (CCCs) and 296 member institutions of the Association of Community Cancer Centers (ACCC) was selected for participation in the survey. Respondents were asked to rate the importance of a recommendation using a five-point scale. Data were analyzed according to hospital bed capacity (small, medium, and large). A total of 175 usable questionnaires were returned, yielding a response rate of 54%. Overall, 99.6% and 94.7% of CCCs and ACCC member institutions, respectively, used vertical-laminar-airflow containment h oods. Personnel used in antineoplastic-drug preparation varied according to hospital size, with CCCs using technicians more frequently than ACCC members. Training methods for personnel were similar among hospitals, although CCCs reported using written testing during training more often than ACCC members. Concern about the safety of the pregnant or breast-feeding woman and of the fetus or infant has led to precautionary policies and procedures in many hospitals. Most hospitals handled antineoplastic waste separately from other waste and regarded this as extremely important. Incineration of antineoplastic waste was used by most hospitals. Antineoplastic-drug-handling precautions taken at CCCs and ACCC member institutions have improved during recent years; pharmacists' perceptions of the importance of various recommendations for handling antineoplastic agents may be helpful in analyzing and developing relevant guidelines.