Gloving and Chemotherapy

Q: Do I need to glove for my own safety when massaging someone who is receiving or has recently received chemotherapy?

A: The short answer is glove if:

Beyond that, the longer answer is there are no definitive answers. Beyond thiotepa, questions have been raised about methoxotrate, cytosine, and cytoxan. The majority view of the S4OM board of directors, based on personal evaluation and input from their oncology department pharmacists, is in line with Gayle MacDonald's analysis in Medicine Hands, reprinted below with permission. (Findhorn Press, 2007, page 69. Available here.)

To put this in perspective, a therapist's chances of exposure are much greater from accidental release: incidental drips or spills, problems with the bag/lines/needle/port (especially when things are not going well), patient pulls needle out, patient tips infusion stand over, defective components, etc.

GLOVING and CHEMOTHERAPY - Gayle MacDonald
Copyright 2007

Antitumor drugs are known for their toxicity. Less well-known is the fact that chemotherapies are, in and of themselves, cancer-causing agents. This makes massage therapists wonder if they should protect themselves when working with chemotherapy patients. Generally, antitumor drugs are eliminated through urine and feces, which poses no threat to massage therapists who are in skin-to-skin contact with a patient undertaking chemotherapy. Only two drugs are known to eliminate through the skin. One, Thiotepa, is the drug for which gloving within 24 hours is a clear necessity. This is based on nursing practice. However, therapists will rarely encounter this medication, so gloving for it becomes a moot point.

The other drug that have been suggested as a candidate for gloving, because it eliminates through the skin to some extent, is cyclophosphamide, also known as Cytoxan.3-7 Many cancer patients receive this medication. But, there is no strong evidence to mandate gloving when massaging clients on this drug. One study showed that health care workers can be exposed to a minute amount of cyclophosphamide 16-24 hours following infusion.3 Based on animal data, this would only account for an extra 1-2 cases of cancer per million workers a year,4 an insignificant risk on the whole.

The scant research that has been done on this topic points to two helpful pieces of information. Cyclophosphamide is not immediately secreted through the skin. Therefore, massage can be safely given during chemo infusion without gloves. Second, cyclophosphamide excretion in the urine peaks 12-18 hours after infusion.5 This provides some evidence that 24 hours is an adequate amount of time to allow the cyclophosphamide to leave the body and that massage can also be given without gloves after that.

On the other hand, comprehensive information on skin excretion and other routes of worker exposure are not readily available or known, so there is an element of uncertainty about massage and gloving. It is important that practitioners be at ease when giving massage. If donning gloves gives them peace of mind, they should not hesitate to wear them. The massage feels no different to the patient whether the practitioner is gloved or ungloved.

For those who would like to pursue the subject further, the following list provides a logical framework.

Massage Therapists and Cyclophosphamide
B.A. Hopkins, BSME, MBA, LMT
Department of Oncology
Mercy Hospital
Portland, Maine

A preliminary calculation of additional cancer risk to massage therapists from
transdermal excretion of cyclophosphamide by chemotherapy patients.

Summary

There is rapidly increasing awareness of the benefits of massage therapy for patients undergoing chemotherapy, however there are suggestions in the literature that massage therapists are placed at increased risk of cancer from chemotherapeutic agents dermally excreted by patients. In a worst-case cyclophosphamide scenario (full body massage, 18-24 hours post infusion, ungloved hands, no hand wash following massage, 200 massages per year) we calculate a maximum probable additional cancer risk of 2.5 extra cases per million massage therapists per year. Risk is reduced by administering fewer than 200 massages per year, administering massage within 6 hours of infusion), massaging less than 100% of the body, using gloves and washing hands post-massage.

Source Data

1. FransmanW, VermrulenR, KromhoutH. Occupational Dermal Exposure to Cyclophosphamide in Dutch Hospitals: A Pilot Study. AnnOccupHyg, v48, n3, 2004, pp237-244. 29 references.

In one aspect of this wider ranging study, Fransman et al measured the cyclophosphamide (CP) removed from the skin of 4 patients by nurse-administered soap and water bath on the morning following intravenous CP administration. CP was found in the soapy wash water, on the washcloth, on the towel, on the nurse’s gloves and on the nurse’s hands. The median yield of CP was 215 mmg (n=4), approximately distributed as wash water/56%, wash cloth/4%, towel/39%, hands and gloves/0.1%.

Purposed Summary: Median overnight dermal excretion of CP by patients following infusion was 215 mmg (n=4).

2. SessinkPJM, BosPB. Drugs Hazardous to Healthcare Workers – Evaluation of Methods for Monitoring Occupational Exposure to Cytostatic Drugs. Drug Safety, 1999, April 20, (4), 347-359. 113 references.

”We have performed a cancer risk assessment of occupational exposure to cyclophosphamide …. we realize that this is a first approach having several pitfalls. The urinary excretion of healthcare workers (mean of 0.18mmg /day) was used to estimate the uptake of cyclophosphamide, which ranged from 3.6 to 18 mmg /day. Based on the animal data … [and] … patient studies, cancer risks were calculated … ranging from about 1.4 to 10 extra cases per million workers.

In the U.S, Sweden, Germany and the European Union, threshold limit values or otherwise defined exposure levels have been introduced for some genotoxic carcinogens in order to protect workers. In the Netherlands, it is proposed that a cancer risk for each compound of 1 extra case per million workers per year (“target risk”) should be sought and that no risk higher than 100 cases per million workers per year (“prohibitory risk”) should be accepted.”

Purposed Summary: Healthcare workers with annual uptake of 72-3600 mmg of CP are at resulting increased cancer risk of 1.4-10 cases/million workers/year.

3. HirstM, MillsDG, TseS, LevinL, WhiteDF. Occupational Exposure to Cyclophosphamide. The Lancet, January 28, 1984, pp186-188. 10 references.

“Urine samples from 5 volunteers were examined after a solution of CP had been applied topically to the cubital fossa area. Variable quantities of CP were identified in urine samples collected over 24h, but in most cases the drug was evident only in urine samples given more than 6h after application.“ Total CP excretion peaked in the 12-18 hour time range.

Purposed Summary: In most cases, urinary excretion of topically applied CP is not evident until 6h after application, peaks in 12-18h, and decays thereafter.

Calculation of Redistribution of Dermal Excretions from Patient to Massage Therapist

Assumptions:
For the purposes of this analysis, it is assumed that dermal excretion is uniformly distributed over the patient’s body surface area and is uniformly mixed with massage crème or oil. It is further assumed that the combination is then uniformly distributed over the patient’s body surface area and the massage therapist’s hand area (both hands, palm and dorsum).

Factors:
By the method of Mosteller, body surface area(m^2) = [height (cm) x weight (kg)/3600]^0.5. For a typical patient, ht=165cm and wt=60kg, body surface area=1.66m^2. For a typical massage therapist, hand surface area = 7cm x 15cm x 2 sides = 210cm^2 per hand. Total hand surface area = 0.042m^2.

Calculation:
The fraction of dermal excretion transferred to the massage therapist is calculated to be 0.042/(0.042+1.66) = 2.5%.

Synthesis - Estimate of Maximum Probable Additional Cancer Risk to Massage Therapist from CP

Assumptions:
a. Massage is administered 18-24h post-infusion.
b. Massage therapist is ungloved and does not wash hands after massage.
c. 100% of CP transferred to massage therapist’s hands is taken up.
d. Massage therapist gives 200 CP post-infusion massages per year.

Factors:
a. 215 mmg CP is dermally excreted by patient 16-24h post-infusion. (Fransman et al)
b. 2.5% of dermally excreted CP is transferred to massage therapist’s hands. (see above)
c. Annual uptake of 720-3600 mmg CP yields extra cancer risk of 1.4-10 cases/million
workers/year. (Sessink et al)

Calculations:
a. Massage therapist annual uptake of CP = 215 mmg x 2.5% x 200/yr = 1075 mmg /yr.
b. By linear interpolation, massage therapist’s maximum probable increased cancer risk is
1.4+(10-1.4)x(1075-720)/(3600-720)= 2.5 cases/million workers/year.

Analysis and Conclusion

A calculated maximum probable increased cancer risk of 2.5 cases/million workers/year is 250% of the Dutch “Target Risk” and 2.5% of the Dutch “Prohibitory Risk” cited by Sessink et al. Risk is reduced by administering fewer than 200 massages per year, administering massage within 6 hours or more than 24 hours after infusion (Hirst, et al), massaging less than 100% of the body, using gloves and washing hands post-massage.

Massage therapists do not appear to be at significantly increased risk of cancer from post-infusion transdermal excretion of cyclophosphamide.

Revised 3/20/2009, Copyright 2006-2009, Bruce A. Hopkins, LMT