Longitudinal assessment of occupational exposure to antineoplastic drugs among healthcare workers: Evidence from a tertiary hospital

• Comprehensive surveillance blueprint: surface + urine monitoring + risk assessment. • Risk-oriented toolkit to enhance worker safety in oncology settings worldwide. • First robust year-long integrated AD surveillance in Portugal. • Widespread surface contamination but no biological contamination. • Surface levels often >100 pg/cm² (safe limit) but <10,000 pg/cm² (action limit). Millions of healthcare workers worldwide handle antineoplastic drugs (ADs) without follow-up of their occupational exposure, preventing evaluation of compliance with guidelines. To support improved workplace safety standards, we aimed to perform the first robust, year-long evaluation of ADs exposure in Portugal, contemplating both environmental and biological samples and risk assessments. Sixty-eight surface samples and thirty urine samples were collected over a year in four sampling campaigns for analysis of fourteen ADs of high concern by liquid chromatography–tandem mass spectrometry. No detectable levels of ADs were found in urine samples, whereas cyclophosphamide, paclitaxel, ifosfamide and/or etoposide were quantified in 64-100% of pharmacy locations and in 33-67% of day-care hospital locations (297 and 518 pg/cm 2 90 th percentiles, respectively) – often above the “safe limit” (100 pg/cm 2 ) but always below the “action limit” (10000 pg/cm 2 ). Occupational exposure was quantified by calculating daily dermal intake values, which were lower than the acceptable daily intake thresholds for both single and multiple drugs exposure. Given the presence of high concern ADs on workplace surfaces, the control banding assessment highlighted that occupational risk for professionals from the evaluated settings cannot be entirely disregarded. Hence, this study provided pertinent information regarding occupational health and safety in this hospital. Moreover, the comprehensive surveillance described is appropriate to assess occupational exposure to ADs – by combining environmental monitoring (visual threshold-based classification), biological monitoring (internal dose quantification) and formal risk assessment – and can be adopted across different oncologic settings. Together, these tools will enhance risk communication and promote evidence-based controls and policies globally.