Healthcare worker protected from chemotherapy exposure

Cytotoxic Exposure: Are You at Risk? Protecting Healthcare Heroes from Hazardous Drug Exposure

Lena Voss monogram
Lena Voss in Health & Wellness November 2026 • 4 min read.

"A cutting-edge urine test offers new hope for monitoring and minimizing the dangers faced by healthcare workers handling antineoplastic drugs."


In the relentless battle against cancer, healthcare professionals face a hidden danger: exposure to antineoplastic drugs (ADs). These powerful medications, while life-saving for patients, pose significant risks to the nurses, pharmacists, and technicians who handle them daily. Studies have linked even low-level exposure to reproductive problems, developmental issues, and other adverse health effects, making it crucial to implement effective safety measures.

For years, guidelines and regulations set by national and international bodies have emphasized precautions for handling cytotoxic drugs. However, monitoring exposure levels has remained a challenge. Traditional methods often lack the sensitivity needed to detect the trace amounts of these substances that can still pose a threat. This is where a groundbreaking new approach comes into play.

Researchers have developed a highly sensitive and versatile assay for quantifying α-fluoro-β-alanine (AFBA), a primary metabolite of the widely used chemotherapy drug 5-fluorouracil (5-FU), in human urine. This innovative test, utilizing reversed-phase ultrahigh performance-tandem mass spectrometry (rp-UHPLC-MS/MS), offers a much-needed tool for biomonitoring and protecting healthcare workers from hazardous drug exposure.

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Scale and Health Impact

About 8 million U.S. healthcare workers are potentially exposed to hazardous drugs. The National Toxicology Program reported on January 7, 2026, that detectable levels of cancer chemotherapy agents continue to be found in workers’ urine and blood samples and in work environments. The CDC reports that antineoplastic drugs can cause long-term organ damage, fertility issues, and cancer among healthcare workers.

Exposure Detection and Pathways

Analytical methods are used to document occupational exposure by measuring antineoplastic drugs or their metabolites in healthcare workers’ urine. Similar methods measure environmental contamination in the workplace. Healthcare workers may encounter hazardous drugs in the air, on work surfaces, clothing, medical equipment, or patient urine and feces.

From Early Evidence to Broader Training

Beginning in the 1970s, evidence indicated that healthcare workers faced harmful effects from occupational exposure to antineoplastic drugs. More recent occupational-safety guidance emphasizes training all personnel who may encounter these drugs, including float pool staff, dietary aides, environmental services workers, and pharmacy technicians. The guidance also recommends emphasizing exposure risks, personal protective equipment protocols, and safety procedures during onboarding, particularly for temporary staff assigned to oncology-related units.

Why is Monitoring 5-FU Exposure So Important?

Healthcare worker protected from chemotherapy exposure

5-Fluorouracil (5-FU) and its oral prodrug capecitabine are mainstays in cancer therapy, used to treat a variety of malignancies. However, these drugs don't discriminate – they can also harm healthy cells. When healthcare workers handle these drugs, even with precautions, small amounts can be absorbed through the skin or inhaled, leading to potential health risks.

AFBA, a breakdown product of 5-FU, is excreted in urine, making it an ideal marker for exposure. By accurately measuring AFBA levels in urine, we can assess the effectiveness of safety protocols and identify areas where improvements are needed. This proactive approach can help minimize exposure and protect the long-term health of healthcare professionals.

  • Early Detection: Identifies exposure even at low levels, allowing for timely intervention.
  • Personalized Protection: Helps tailor safety measures to individual needs and work practices.
  • Improved Safety Protocols: Provides data to refine and optimize handling procedures.
  • Reduced Health Risks: Minimizes the potential for long-term health consequences associated with cytotoxic drug exposure.
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CSTD-Linked Reduction

A multicenter study examined 5-fluorouracil environmental contamination and occupational exposure to its metabolite, alpha-fluoro-beta-alanine, during routine anticancer-drug preparation at Japanese cancer centers. In the study, environmental contamination when a closed-system transfer device was used was 8%. This was significantly lower than contamination without a closed-system transfer device, with p < 0.001.

Limits of Monitoring and Policy

One French healthcare-setting study selected four antineoplastic drugs as exposure markers, even though more than thirty are commonly used in healthcare departments. This limited marker selection may not represent exposure to every antineoplastic drug used in practice. Prevention strategies also depend on healthcare institutions adopting policies and procedures that protect nurses’ health and safety in line with the National Institute for Occupational Safety and Health Total Worker Health approach.

Different Biomonitoring Results

A study using a highly sensitive UHPLC-MS/MS method found alpha-fluoro-beta-alanine in seven of 73 urine samples from healthcare professionals exposed to 5-fluorouracil, indicating 5-fluorouracil contamination in 9.6% of samples. The reported urine concentrations ranged from 25 to 301 pg/ml. By contrast, a separate descriptive pilot study found that all 128 urine samples from 18 workers were negative for cyclophosphamide, ifosfamide, methotrexate, and 5-fluorouracil.

The new rp-UHPLC-MS/MS assay represents a significant advancement over previous methods. It's more sensitive, reliable, and easier to implement, making it a practical tool for routine monitoring in healthcare settings. The method involves a streamlined process of urine sample preparation, followed by precise measurement of AFBA levels using sophisticated mass spectrometry techniques.

The Future of Healthcare Worker Protection

The development of this highly sensitive AFBA assay marks a crucial step forward in protecting healthcare professionals from the dangers of cytotoxic drug exposure. By providing a reliable and practical means of monitoring exposure levels, this innovative tool empowers healthcare facilities to create safer working environments and safeguard the health of their dedicated staff. Further research and broader implementation of this technology promise a future where those who care for us are better protected from the risks they face.

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Experience, Training, and Worker Health

A 2026 study of occupational safety performance in chemotherapy handling included questions about workers’ chemotherapy-specific experience, participation in chemotherapy-related training, history of skin contact with chemotherapy agents, and self-reported health hazards or side effects. These factors connect exposure prevention with workers’ everyday experiences and perceived health effects. The Pan American Health Organization and World Health Organization identify healthcare-worker exposure to antineoplastic drugs and other hazardous drugs as an important issue in broader efforts to reduce occupational cancer.

How exposure measurements compare across settings

  • 31% of 32 urine samplesA separate assessment found detectable cyclophosphamide in 10 of 32 urine samples, or 31%, with nurses having the most positive samples among the personnel categories.[1]
  • 60.8% rather than 17.6% contaminationWith a more sensitive analytical approach, reported contamination would have been 60.8% rather than 17.6% using methods then published, showing how detection limits can change the apparent frequency.[2]
  • 40% of urine samplesAnother assessment reported detectable cyclophosphamide in 40% of urine samples, a result that provides a separate comparison for biomonitoring findings.[3]
  • 0.3–168.9; up to 21,300 ng/cm2Reported surface contamination ranged from 0.3 to 168.9 ng/cm2 in one comparison, while another report described contamination as high as 21,300 ng/cm2.[4]

What urine and surface results can tell us

Urine testing and surface wipes capture different parts of the exposure picture. The lack of a statistically significant relationship between the two in the reviewed studies means a surface result cannot be treated as a direct stand-in for a worker’s urine result.[5]

Because protective equipment and handling practices were directly assessed in only one study, differences in those practices could complicate comparisons of measured absorption across workers.[5]

The evidence also points to workplace conditions as part of the explanation for contamination: workload, procedures and the drug’s solubility can affect how much residue remains on surfaces.[6]

What other occupational assessments add

A small assessment of cyclophosphamide and ifosfamide involved workers in one oncology setting at a tertiary care center. Its restricted workforce and setting limit how broadly its results can be applied.[3]

A review noted that workers without training had higher urinary cyclophosphamide levels, linking training status with measured exposure in those reports, though that association alone does not establish cause.[1]

What exposure monitoring still leaves unresolved

  • Would daily work diaries, paired with environmental and urine measurements, better characterize how exposure changes across workers’ tasks and time?[7]
  • How could monitoring distinguish among several drugs at once, rather than leaving exposure to agents outside a selected marker set uncharacterized?[7]

Sources

  1. Exposure to Antineoplastic Drugs in Occupational Settings: A Systematic Review of Biological Monitoring Data (pmc.ncbi.nlm.nih.gov)
  2. Nurses' internal contamination by antineoplastic drugs in hospital centers: a cross-sectional descriptive study. (pubmed.ncbi.nlm.nih.gov)
  3. Biological Monitoring of Healthcare Workers Exposed to Antineoplastic Drugs: Urinary Assessment of Cyclophosphamide and Ifosfamide (pmc.ncbi.nlm.nih.gov)
  4. Environmental Contamination and Occupational Exposure of Algerian Hospital Workers (www.frontiersin.org)
  5. A review of surface wipe sampling compared to biologic monitoring for occupational exposure to antineoplastic drugs. (pubmed.ncbi.nlm.nih.gov)
  6. Occupational Exposure Assessment to Antineoplastic Drugs in Nine Italian Hospital Centers over a 5-Year Survey Program (pmc.ncbi.nlm.nih.gov)
  7. NTP Monograph: Systematic Review of Occupational Exposure to Cancer Chemotherapy Agents and Adverse Health Outcomes; March 2019 (ntp.niehs.nih.gov)

About this Article -

Written with AI assistance from published research, and reviewed by the Mystum team. See our About page for more information.

Everything You Need To Know

1

What are antineoplastic drugs (ADs) and why are they a concern for healthcare workers?

Antineoplastic drugs (ADs) are medications, like 5-Fluorouracil (5-FU), used to treat cancer. They're significant because while they save lives, they can be harmful to healthcare workers who handle them. Exposure, even at low levels, has been linked to health problems, making monitoring and safety measures essential. The development of the AFBA assay helps measure the presence of these drugs to protect healthcare workers.

2

How does the α-fluoro-β-alanine (AFBA) assay work, and what makes it a valuable tool?

The α-fluoro-β-alanine (AFBA) assay utilizes reversed-phase ultrahigh performance-tandem mass spectrometry (rp-UHPLC-MS/MS) to detect AFBA, a metabolite of 5-Fluorouracil (5-FU), in urine. This is important because AFBA serves as a biomarker for exposure to 5-FU. By measuring AFBA levels in urine, healthcare facilities can assess the effectiveness of their safety protocols and take steps to reduce exposure.

3

Why is it so important to monitor healthcare workers' exposure to 5-Fluorouracil (5-FU)?

Monitoring exposure to 5-Fluorouracil (5-FU) is important because this drug, while effective against cancer, can harm healthy cells. Healthcare workers can absorb small amounts through the skin or by inhaling it while handling it. Measuring α-fluoro-β-alanine (AFBA), a breakdown product of 5-FU, allows for the assessment of safety protocol effectiveness, reducing potential long-term health risks.

4

What is reversed-phase ultrahigh performance-tandem mass spectrometry (rp-UHPLC-MS/MS) assay and how does it improve healthcare worker safety?

The reversed-phase ultrahigh performance-tandem mass spectrometry (rp-UHPLC-MS/MS) assay is an advanced method for measuring α-fluoro-β-alanine (AFBA) levels in urine. It's more sensitive, reliable, and easier to implement than previous methods. It improves healthcare worker safety by providing accurate exposure data, enabling timely intervention, personalized protection, and optimized handling procedures. It's streamlined process helps protect dedicated staff.

5

What are the main advantages of using the α-fluoro-β-alanine (AFBA) assay for monitoring exposure?

The key benefits of using the α-fluoro-β-alanine (AFBA) assay are early detection of exposure, personalized protection through tailored safety measures, improved safety protocols based on data, and reduced long-term health risks associated with cytotoxic drug exposure. It offers a proactive approach to minimizing exposure and safeguarding the well-being of healthcare professionals. This includes improved urine sample preperation and precise measurement of AFBA levels.

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