Image: Sue Crump
Paul Joseph Brown  /  Paul Joseph Brown Photography
Sue Crump prepares to receive chemotherapy for pancreatic cancer at Evergreen Hospital in Kirkland, Wash., before her death last September. Before her diagnosis, she spent 23 years mixing chemo as a hospital pharmacist and believes the years of toxic exposure caused her own cancer.
updated 7/11/2010 12:44:32 PM ET 2010-07-11T16:44:32

Sue Crump braced as the chemo drugs dripped into her body. She knew treatment would be rough. She had seen its signature countless times in the ravaged bodies and hopeful faces of cancer patients in hospitals where she had spent 23 years mixing chemo as a pharmacist.

Now she hoped those same medicines would kill the tumor cells lurking in her belly. At the same time, though, she wondered whether those same drugs may have caused her cancer to begin with.

Harnessing toxic agents to save a life demands a delicate balance. Chemo is poison, by design. Descended from deadly mustard gas first used against soldiers in World War I, now it’s deployed to stop the advance of cancer.

Crump knew she had her own war on her hands. And she wanted young pharmacists and nurses to pay attention to her story.

Little workplace regulation
The same powerful chemotherapy drugs that have saved hundreds of thousands of patients’ lives for decades have at the same time potentially taken a deadly toll on the hospital and clinic workers who handled them.

Crump, who died of pancreatic cancer last September at age 55, was one of thousands of health care workers who were chronically exposed to chemotherapy agents on the job for years before there were any safety guidelines in place.

Now, some of those workers, like Crump, are being diagnosed with cancers that occupational health specialists say could be linked to that exposure.

Their ranks include Bruce Harrison of St. Louis, Karen Lewis of Baltimore  — both pharmacists —and Brett Cordes, a veterinarian from Scottsdale, Ariz. All, like Crump, worked extensively with or around chemotherapy. (See profiles below.) All of them eventually got cancer, or in Lewis’ case a pre-cancerous condition.  All believed their disease was linked to workplace exposures and became symbols for increased safety. Cordes, who was diagnosed four years ago at age 35, and Lewis, who was diagnosed in her 50s, are both undergoing treatment. Harrison died at age 59.

Tracing an individual’s cancer to a particular exposure is difficult. It’s one of the main reasons safety advocates have been thwarted in their efforts to get stricter regulations. But many who study these agents fear lax safety standards are resulting in ongoing exposures that continue to put current workers at future risk.

A just-completed study from the U.S. Centers for Disease Control, 10 years in the making and the largest to date, confirms that chemo continues to contaminate the workspaces where it’s used, and in some cases is still being found in the urine of those who handle it, despite knowledge of safety precautions.

"There is no other occupation population (that handles) so many known human carcinogens,” said Thomas Connor, a research biologist with the National Institute for Occupational Safety and Health. Connor has spent 40 years studying the effect of chemo agents on workers, and is one of the lead authors on the latest study.

Chemo agents have been classified as “hazardous drugs” by the Occupational Safety and Health Association (OSHA.) Hazardous drugs are those known, or suspected to cause cancer, miscarriages, birth defects, or other serious health consequences.

Paul Joseph Brown  /  Paul Joseph Brown Photography
Patty Allen, a long-time friend, holds Sue Crump's hand during a visit to say goodbye to her in hospice care in Kirkland, Wash.

But an InvestigateWest investigation has found that OSHA does not regulate exposure to these toxic substances in the workplace, despite evidence of ongoing contamination and exposures.

While Deputy Assistant Secretary of Labor for OSHA Jordan Barab said the agency “has been concerned about the potential for healthcare workers to be exposed to hazardous drugs for some time,” he conceded in written responses to questions from InvestigateWest that the agency does not have the resources to issue standards “covering every safety and health hazard facing workers.”

“Although this is an important safety and health issue, OSHA has not considered a standard to specifically address hazardous drugs in the healthcare setting,” he wrote.

OSHA has no regulatory authority to enforce safety practices with fines or sanctions, other than under its “General Duty” clause — a catch-all regulation that allows OSHA inspectors to warn an employer if they see something that concerns them.

According to documents obtained by InvestigateWest through the Freedom of Information Act, OSHA has only used the clause once in 10 years to cite any health care institution, including hospitals, clinics, dental and veterinary offices, for their handling of hazardous drugs.

Longterm exposures to ‘just a little bit’
A few months before she died, Crump sat in a coffee shop near her home in suburban Seattle, and perused a list of chemo drugs now deemed hazardous for health care workers to handle. She ran her fingers down the page. It’s a long list: cyclophosphamide, doxorubicin, fluorouracil, methotrexate. And the list went on.

“Yeah, I worked with all of them,” she said.

Crump started at Seattle’s Swedish Medical Center in the early 1980s, before pharmacists used special protective “hoods” over countertops to contain spray and chemo contamination. They didn’t use gowns, or gloves.

They had no reason to think they should. 

Occasionally, drugs would spill on the countertops.

“We would wipe if off and throw (the towels) in the garbage,” Crump said. “Most of the chemo came in vials, and we would transfer it into plastic IV bags.”

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Sometimes there would be spray when they punctured the vials.

Other drugs came in ampoules and would be squirted, she said. “I’d file the neck of it, then snap real fast, she said. “A lot of times, I got cuts.”

“But the feeling at the time was – whatever little vapors or splash – it was such a low exposure through the skin, it was insignificant.”

That was a common attitude then — and even now, said Dr. Melissa McDiarmid, director of occupational health at the University of Maryland in Baltimore.

“So many people think it’s just a ‘little bit.’ They don’t understand, it’s a little bit of something designed to be toxic, and to be highly absorbed biologically.”

A silent threat
Multiple studies going back decades have found evidence of contamination in areas where workers prepare and deliver chemotherapy. Still more studies, done by Connor and others around the world, have found these agents in the blood and urine of nurses and others who handle them.

Danish epidemiologists used cancer registry data from the 1940s through the late 1980s to report a significantly increased risk of leukemia among oncology nurses and physicians. Last year, another Danish study of more than 92,000 nurses found an elevated risk for breast, thyroid, nervous system and brain cancers in the nursing population.

“It’s been a silent threat for a long time with very little attention by the government,” said Bill Borwegen, occupational health and safety director for the Service Employees International Union, the labor union that represents nurses nationally.

“We are concerned how they are handled. There’s such a dearth of info on how to sample these agents. People don’t know how to clean surfaces.”

Chemotherapy agents, when dispersed in the air or onto surfaces, are invisible, difficult to clean, long-lasting, easily spread and capable of causing genetic damage. They’ve been found on the outsides of the drug vials shipped from manufactures, on floors and countertops, on keyboards, garbage cans and door knobs.

Researchers at NIOSH, a division of the CDC, were so concerned they issued an extensive alert about handling high-risk drugs. The guidelines, published in 2004, urge strict precautions, including use of impervious chemo gowns, double-gloving, use of sophisticated “closed-system” devices and specialized ventilation hoods, face shields and respirators, clean rooms and other precautions.

But the NIOSH guidelines outlined in the alert are voluntary.

That’s wrong, said McDiarmid. “We can no longer have these be optional. ... We’re talking human carcinogens here.”

Chemo the home and at the vet’s office
Ten years into Crump’s career, reports of health effects related to chemo exposure began to surface in Europe and health care workers started adopting rudimentary safety procedures.

Her pharmacy manager took the warnings seriously and installed special ventilated hoods in the workspaces — considered state-of-the-art at the time.

The trouble was the hoods were designed to keep chemicals sterile by blowing contaminants away from them and back out of the hood, exposing any workers standing behind it.

Safety practices have evolved over the years. The hospital now has a special dedicated area for mixing chemo, and uses a different type of hood that no longer blows air out the back. Workers wear special gowns, gloves and sleeves, and take other precautions to keep chemo from spreading around, said Lanny Turay, manager of pharmacy operations at Swedish Cancer Institute.

Still, Crump wondered whether those early, ongoing exposures had contributed to the cancers she and her peers had developed. She first recalled getting alarmed after a pharmacy tech – someone with whom she mixed a lot of chemo — died at age 29 of a brain tumor. Around the same time, several colleagues experienced miscarriages.

Since that time, a number of studies have shown an association between exposure to chemo agents and reproductive issues including miscarriage, birth defects and low birth weights. A 2005 survey found significant associations with infertility and miscarriage in nurses who handled chemo before the age of 25. Nurses who administered nine or more doses of chemo a day had a greater chance of pre-term labor, or having children with learning disabilities.

Safety advocates are especially worried about workers in smaller clinics, where awareness is not as high, and expensive equipment may be less available.

There are more than 5.5 million workers involved in nursing, pharmacy, transport and cleanup of chemo waste. Of those, experts estimate about 2 million actually mix or dispense chemo.

Those numbers will grow as the ranks of cancer patients climb by a projected 50 percent in the next decade as the population ages. More people will be required to prepare and deliver their treatment. And more of those people will likely be in non-hospital settings such as clinics or private homes.

In addition, chemo drugs have found wider application — in the treatment of arthritis, multiple sclerosis and other diseases.

Veterinarians are now increasingly using these drugs to treat animals, putting those who work in vet’s offices in contact with chemo.

Generic drugs have made the treatment more affordable for pet owners, said Cordes, a former veterinarian and one of the cancer patients interviewed for this article.

Cordes, who became a safety consultant after he was diagnosed with thyroid cancer, said he, like many vets he’s spoken with, handled chemo without understanding its dangers.

“We slip through the cracks.”

Crump’s last wish before her death on Sept. 13 was that fewer health care workers would risk their lives without understanding the risks.

“Safety needs to be revisited,” she said. “People don’t take this seriously enough.”

InvestigateWest is a non-profit investigative news organization covering the environment,  health and social justice. Find out more at © 2012 InvestigateWest

Explainer: Profiles of exposure: Health care workers share lessons

  • Karen Lewis: Call for screening

    Image: Karen Lewis
    Courtesy of Karen Lewis

    Karen Lewis knew what the possibilities were when a routine medical exam returned an abnormal white blood cell count on her four years ago. “I worked in a cancer center,” she said. “I knew.”

    The long-time hospital pharmacist, 57, was soon diagnosed with a pre-cancerous blood disease called myelodysplastic syndrome. Her doctor immediately ordered her to stop working with or around chemo agents.

    “I started working with chemo in 1993,” said Lewis, who has worked for years at the University of Maryland Medical Center in Baltimore. “Back then there were much less restrictive policies (around handling chemo).”

    Her attitude then was similar to those of many of her peers. They had been advised to wear “chemo protective gowns” made of heavy paper, with little cuffs, and double gloves. “But nobody really did (wear double gloves) because it made it hard to manipulate needles. And no one said if we didn’t follow (the guidelines) we were at any greater risk.”

    She also doesn’t recall being advised to wear a mask. “My thinking was if I don’t actually stick myself or spill on skin, I’m OK,” she said. “I never thought of any other way (it could be) adversely affecting me.”

    In particular, she never realized that the type of “laminar flow hoods” the hospital used — the commonly recommended type at the time — blew potentially contaminated air back in her direction.

    Since her diagnosis, she said the pharmacy where she worked has tightened its controls and upgraded its safety equipment.

    Lewis has begun transfusions to try to keep her cell counts normal. Ultimately, her only hope for a cure lies in a bone marrow transplant. She advises others to be vigilant about cancer screening if they’ve worked with chemo.

    “Now, since I left, everybody who works with chemo has to have a blood test once a year and urinalysis,” she said. “Maybe that was my contribution.”

  • Brett Cordes: Veterinarian’s new role

    Image: Brett Cordes
    Courtesy of Brett Cordes

    Brett Cordes had been a practicing veterinarian for nearly a decade when he was diagnosed at age 35 with thyroid cancer. One of the first questions his doctor asked him was whether he handled chemotherapy agents. “He said they see a link between chemo and thyroid cancers,” Cordes said.

    Cordes is in good health now, four years later, after being successfully treated but said his diagnosis “changed my life. I quit my practice and made it my passion to improve oncology safety for vets.”

    Animal oncology has exploded within the last decade as some of the most common chemotherapeutic drugs became available as generics. Instead of paying $1,200 a vial, it is $12 to $15 a vial, he said. “That opened the flood gates.”

    Charlie Powell, spokesman for the College of Veterinary Medicine at Washington State University in Pullman, Wash., said the number of vets who handle chemo is low, and those who do receive specialized training and take precautions similar to those required for human medicine. "It's very safe to say the vast majority of vets in practice will never give a chemo dose and will refer to cancer specialists," he said.

    Cordes said he sees that changing. He estimates about 4,000 general practices in the United States administer a few doses a month, often with no special precautions in place

    The potential risk extends to pet owners, too, he said, because of the length of time the drugs persist in the environment. If someone brings their dog in for treatment, and the dog is later throwing up at home, the people in the house are potentially being exposed.

  • Bruce Harrison: Career may have cost him his life

    Image: Bruce and Kathy Harrison
    Courtesy of Harrison family

    Bruce Harrison had been an oncology pharmacist since the late 1970s. He had seen the evolution — or lack of it — in safety awareness during that time, but he spent much of his career trying to change attitudes toward safe practices through research.

    Harrison, who for years was a clinical pharmacy specialist with the Department of Veterans Affairs Medical Center in St. Louis, was also one of the authors of the strictest set of voluntary guidelines, issued in 2004 by the National Institute for Occupational Safety and Health, for the safe handling of chemo and other hazardous drugs for health care workers.

    These practices, had they been in place throughout his career, might have saved his own life.

    Harrison died at age 59 in St. Louis last August of a rare form of oral cancer. He had never smoked or chewed tobacco. He had no other known risk factors, except he had mixed a lot of chemo for other people in his career as a pharmacist. He discussed it with his doctor.

    “There was no way they could prove it, but the two of them decided it could be related,” said his widow, Kathy Harrison. “Bruce absolutely believed it was triggered by his exposure.”

    She’s grateful her husband had a long career doing something he loved. She’s also sad, and frustrated, that it may have cost him his life. And she worries it will cost others theirs.

    “What frustrated him the most, there was not enough done — not enough studies done to prove it was the danger it was,” said Harrison. “I think there needs to be more done to provide more providers with safe handling techniques.

Video: Sue Crump, in her own words


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