How Do You Dispose of Cytotoxic Waste?
Throughout Canada and across provincial and territorial borders, the identification of cytotoxic waste is essential in order to promote safe handling and disposal. Understanding how to label, pack, and dispose of potentially toxic waste is essential not only for the protection of healthcare providers handling such substances, but also for transporters and waste facilities that dispose of it.
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What is cytotoxic waste?
Cytotoxic waste is a chemical, drug, or pharmaceutical that is toxic to cells. In other words, it kills cells. In their publication “Safe Handling of Hazardous Drugs in Healthcare,” the Public Services Health and Safety Association defines cytotoxic drugs – also known as antineoplastic drugs – as agents used in chemotherapy procedures to control or kill cancer cells. The terms “antineoplastic” and “cytotoxic” are often used interchangeably throughout Canada.
Several regulatory agencies have their pulse on environmental concerns regarding improperly disposed of healthcare, pharmaceutical, and especially, cytotoxic or toxic wastes. Federal departments have created numerous acts that focus on substances and products of biotechnology to reduce risk to not only human health, but the environment as well.
Proper handling of cytotoxic drugs and waste
Proper handling focuses on safety, reduction, and prevention of exposure to healthcare professionals outside of the treatment room where chemotherapy or other procedures are conducted using cytotoxic drugs.
It doesn’t stop there though.
Proper packaging, storage, and disposal options also help to protect anyone handling cytotoxic waste. Whether it’s a hospital, a cancer care centre, or a pharmacy that supplies such drugs, waste generators are responsible for the duty of care for how cytotoxic waste is disposed of. Certain steps are made to ensure protection of not only the general public, but the environment.
What can a cytotoxic drug do to a healthy person? The basic function of such drugs are to interfere with the growth and function of not only diseased cells, but also affect healthy cells, as a result of toxic side effects. The US National Institute for Occupational Safety and Health (NIOSH) has identified the primary characteristics of hazardous drugs, which are also acknowledged through Canadian provinces and territories. They include:
- Carcinogenic – an agent or substance that can cause cancer
- Teratogenic – an agent that can cause fetal malformation
- Reproductive toxicity – has adverse effects on both male and female reproductive systems, which can lead to fetal loss during pregnancy as well as decreased fertility
- Genotoxic – implying an agent or substance that causes lack of integrity in cellular genetic materials, otherwise causing damage or mutations to DNA
Organ toxicity at low doses – implies damage or toxicity to health or organs such as liver damage, or local damage or necrosis to exposed tissues
The Canadian Union of Public Employees also recognizes the term “mutagenic,” which defines a substance that can alter the DNA of a living human being, increasing the chance of mutations.
While patients may assume the risk of potential toxicity, the risk of exposure to healthcare professionals is also of concern. These can include any individuals involved in the chain of treatment from a nurse or physician to laboratory professionals, shipping and receiving personnel, housekeeping staff, and other support workers.
The most common route of exposure is through contact with an object, body fluid, or surface that has been contaminated with a cytotoxic substance, as well as an accidental needle stick. The processes involved in chemotherapy or radiotherapy itself require handling and disposal of the equipment used in drug administration or other contaminated waste, such as contaminated body fluids or feces of the patient.
Safer handling and storage of cytotoxic waste
Every facility that utilizes cytotoxic or antineoplastic drugs should ensure proper training regarding the hazards of cytotoxic drugs as well as disposal procedures and proper use of personal protective equipment (PPE).
The Canadian Union of Public Employees provides recommendation for waste disposal of cytotoxic drugs in “plastic bags that are at least 2 mm thick (if polypropylene) or 4 mm thick (if polyethylene)” for contaminated materials. Such bags are to be properly colour-coded and labelled with the cytotoxic warning label.
According to CAREX Canada (CARcinogen EXposure), approximately 75,000 Canadians are exposed to antineoplastic agents at work, most of them being nurses or pharmacy staff. Antineoplastic agents are classified by their potential dangers for adverse health outcomes. These include:
- Carcinogenic to humans
- Probably carcinogenic to humans
Possibly carcinogenic to humans
Among the most prevalently antineoplastic (cytotoxic) drugs used in treatments today include:
- Arsenic trioxide
Safe handling procedures, as well as education and training, is required for all staff and facilities who utilize cytotoxic/antineoplastic drugs in order to reduce risk of exposure. This includes sanitary services and housekeeping staff who may be exposed through laundry, housekeeping, or waste management processes.
All cytotoxic/antineoplastic drugs and waste should be stored in a contained and isolated area with proper ventilation (ideally with negative air pressure) in order to reduce the amount of drug residues in the air. Refer to your provincial guidelines regarding storage recommendations as well as manufacturer guidelines depending on the drug and its half-life.
Disposal of cytotoxic waste
While guidelines may be slightly different from province to province, the basics remain the same. For example, Cancer Care Ontario provides guidelines for the Safe Handling of Cytotoxics, which includes general guidance and recommendations for the safe handling of cytotoxic drugs by healthcare workers.
Segregation and identification of cytotoxic/antineoplastic waste is essential. Federal legislation requires that cytotoxic drugs and associated waste be correctly identified by labels or placards with a red triangle on a gray background with a white “C” in the middle. Underneath the symbol the words Cytotoxic/Cytotoxique must be found in capital letters. (The Ministry of Environment requires bilingual wording.)
Cytotoxic material, including IV tubing, syringes, IV bags, and so forth, are to be placed into a rigid, leak-proof transport container that has been properly identified with the cytotoxic hazard symbol. Containers are to be CSA Standard Z31 6.6-7 and red-coloured, rigid, and leak-proof.
Cytotoxic drugs and their wastes should be segregated from other waste streams and packed separately according to the manufacturer and distributor as well as federal and provincial recommendations. If in doubt, refer to pharmaceutical professionals as well as local municipal and provincial governments for specifics regarding disposal. Provincial legislative agencies may have different guidelines for the storage, handling, and disposal of packaging materials, personal protective equipment, and procedure preparation supplies as well as waste from a patient who has just received chemotherapy or radiotherapy procedures.
It is also recommended that anyone who handles such drugs be aware of their half-life for safer disposal. For example, arsenic trioxide has a half-life of one to two days, while tamoxifen has a half-life that averages five to seven days, but can range anywhere from four to 11 days. At the other end of the spectrum, busulfan has a typical half-life of 2.5 hours.
Safe cytotoxic waste disposal
Daniels Health Canada promotes safe cytotoxic waste disposal, primarily through proper education and training of all healthcare personnel involved in such procedures. We also provide numerous resources, products, and services for the handling of cytotoxic waste. For additional information regarding our services options and waste management processes, contact us. Safety first, not only for healthcare providers, but for the environment too.