Secondary packaging of cytotoxics: which elimination process should be adopted?

Introduction
Cytotoxic anticancer (AC) treatments are carcinogenic, mutagenic and reprotoxic agents. Their disposal is regulated by the Good Preparation Practices of 2022 and the Interministerial Circular No. 58 of 13 February 2006. There are three disposal circuits: waste that can be assimilated to household waste (DAOM), waste contaminated with anticancer drugs (DASRI) incinerated at 800°C and concentrated anticancer drugs incinerated at 1200°C. Although the management of AC waste are detailed, there are no recommendations for the disposal of secondary packaging (SP). The aim of this study is to optimize the SP disposal circuit for injectable anticancer drugs in our Cytotoxic Drug Reconstitution Unit (CDR).

Materials & Methods
A benchmarking study of disposal circuits was carried out in 11 hospitals. A single-centre prospective study of the elimination of cytotoxic SP was then carried conducted over one month in our CDR. The budget impact resulting from the use of each disposal circuit was calculated. Finally, cytotoxic concentrations were determined by high-performance liquid chromatography (HPLC) after sampling cytarabine SP at 20 mg/ml (n=6) and 100 mg/ml (n=6).

Results
Of the 11 hospitals questioned, 55% used the DAOM circuit, 27% the DASRI circuit and 18% incineration at 1200°C to dispose of their cytotoxic CS. In our CDR, cytotoxic SP represented 450 liters (L) of waste over the study period. These SP can be divided into 4.5 100L bags of DAOM, 9 50L bags of DASRI or 7.5 60L drums for incineration at 1200°C. Depending on the circuit chosen, the monthly budget impact is 15.39€ for DAOM, 31.5€ for DASRI and 55.65€ for incineration at 1200°C. The HPLC analysis detected cytarabine in n=2 SP at 20 mg/mL (concentrations of 0.07 ng/mL and 0.27 ng/mL). No concentration was detected in SP at 100 mg/mL.

Discussion - Conclusion
The heterogeneous circuits for the elimination of anticancer SP demonstrate the difficulty of interpreting the soiled nature of a waste product. The risk of cytotoxic contamination of personnel and of the environment by SP is well-documented in literature and has been confirmed through analytical dosage. The use of a DASRI circuit for cytotoxic SP seems to be the most suitable choice, with an additional annual cost of 193.32€ compared with a DAOM circuit, which will be reserved for antibodies SP. This is part of the Corporate Social Responsibility approach adopted by healthcare establishments. Teams will be reminded of the need to wear personal protective equipment when handling SP.