Background Antineoplastic drugs (ADs) that are carcinogenic, teratogenic and mutagenic are prescribed to manage cancer and immune diseases. Through patient care activities, many healthcare workers (HCWs) are routinely exposed to ADs.

These drugs are associated with secondary cancers along with established evidence on adverse occupational reproductive outcomes but due to lack of precise exposure assessment tools, evidence regarding occupational cancer risks following long term occupational exposures is limited and there is concern for additional risk due to interaction between multiple drug exposures.

Despite safe handling guidelines, recent evidence describes continued exposure to ADs among HCWs, in particular pharmacists and nurses, and also suggest a wider range of hospital occupations may be at risk.

Methods We conducted:

Systematic review of evidence for biological exposures to cyclophosphamide among HCWs and lifetime cancer risks assessments.

Observations and job shadowing of local oncology personnel performing associated tasks. The HCWs’ interactions with each other and their environment were monitored for transmission of contamination.

Discussions with stakeholders evaluated the impact of policies, procedures and settings on HCWs’ exposures.

Results HCW’s AD urinary contamination levels have been decreasing over the years. Animal and human models were used to quantify the occupational lifetime risks for cancer. Results based on pharmacists and nurses suggest elevated lifetime risks for bladder cancer and leukaemia.

Observations suggest that despite precautionary actions, exposures cannot be controlled without considering the entire hospital AD network. Interviews of stakeholders confirmed the existence of gaps that enable contamination.

Conclusions The entire health care facility should be investigated to address gaps in the control of AD exposures through network analysis of contacts and probabilities for contamination for each AD related task; technological improvements are needed for safer preparation, delivery, administration and disposal of ADs; changes in policies are required to address the entire AD system, from ‘cradle to grave’.